Every so often, as an anaesthetist, you know the patient may not wake up and that you will be the last person they ever speak to. This operation may be their last chance at survival but it may also be the very instrument which ends their life. Something has ruptured. They may be bleeding. You don’t know if you can “turn off the tap”. The patient may be frail but you must at least give them the chance.

Getting them through the operation can be the easy part but the body has suffered enough and simply does not have the reserve to deal with the trauma. They remain sedated as the feeling of a breathing tube and the nature of being a patient in intensive care would be as unpleasant as the operation itself. You keep them alive but only under the immense power of an arsenal of drugs reserved for these circumstances. You keep them alive with the hope they may pull through, but occasionally only so their loved ones can be by their side at the moment of passing.

Barriers may unintentionally fall and their true feelings are revealed, possibly followed by a knowing laugh

A patient’s last words can be deeply profound, even prophetic of their own mortality. They can be completely ignorant of their condition through delirium or dementia. Vital organs only take minutes to become irreversibly damaged. They need oxygen, they need blood and the body’s systems are failing, often before your eyes. Sudden confusion, unconsciousness, abnormal breathing, all signs of impending shutdown. You have to take over, you have to replace that which has failed. A tube to deliver life-sustaining oxygen, fluids or blood to replenish what was lost, and anaesthesia to rest a frantic brain and spare the memory of any suffering.

Those who you can talk to you reassure. You tell them everything will be done to wake them and that there will be no pain, they will not suffer. They understand. Reassurance is easy, a few simple words spoken honestly and calmly. You gauge the mood and ask them about who is waiting for them when they awaken. How long have you been married? What kind of dog do you have? Find the right path to follow and they will lead you down a road of conversation which lasts until the point of unconsciousness. Barriers may unintentionally fall and their true feelings are revealed, possibly followed by a knowing laugh. They know their secrets are safe.

Revelations range from patients, previously brave-faced, who confess their terror at the prospect of never waking, to those who divulge a sense of abandonment of life. They have suffered enough and want this sleep to guide them gently to death. One patient admitted to having enjoyed a cheeky slug of whisky a friend had smuggled to him just before coming to theatre. People share a joke and a smile. The release of a smile is echoed in the slowing heart rate only associated with feeling calm and relaxed. The beeping machine that monitors their heart becomes a metronome of their emotion.

I remember one man who was brought to theatre for an emergency operation. He was dying but nobody knew when. The cancer had spread and was now blocking his gut. He knew the operation might kill him but wanted to take the chance that he may survive long enough to leave hospital to organise his affairs and be with his loved ones at the end. His mood struck us all. He was dying yet had a smile on his face and was quick to share a joke. No one said “see you afterwards” as we most often do, we just invited him to think of somewhere he would rather be. He smiled again – “anywhere but here” – and laughed. He never spoke again. He passed away under anaesthesia the following day with his family by his side.

Only in the hours or days following the event does the poignancy hit you. You start to reflect on not only the words themselves but the underlying emotions the patient was experiencing. There is a sadness, especially when speaking to a patient’s loved ones, but the opportunity to reflect provides a chance to learn and question your own practice. Your normal bedside manner was aimed at inducing calm before the anaesthesia itself. Did it work? Did you quell the fear in any way? Could anything have been said differently or not at all?

A person’s last words can be a defining moment. You speak to families and you tell them there was a smile, even a giggle. The fact that this was their last conscious, communicated thought will hold in the memory of anyone who cared for them. “Yep, that sounds like him!” Another smile. A seemingly impossible moment of happiness.

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