Last ditch, last minute, eleventh hour: all expressions allowing a relieved sigh. There are no single, non-metaphorical words to replace them. Ultimate, late and final appear in lists of synonyms, but they don’t give the sense. Last minute and eleventh hour are synonymous: something done before time has run out. Last minute has always been more popular than eleventh hour, increasingly so in recent years: four times more common on Ngram in 1960, it is now nine times more common, as its prevalence has increased and that of eleventh hour has decreased.

Last minute is also more common in PubMed, but many of its occurrences are literal: measurements made in the last minute of a period of observation. Last minute is barely a metaphor at all, but “Despite the best of intentions, we often act at the last minute when we are faced with a deadline” does not mean—probably—that it is literally the last minute; it is—probably—the last day. So, “a last minute concession by DoH led to a deferment”, “a ‘near miss’ where harm is avoided at the last minute”, and “giving a ‘last minute’ choice to the patients” are all good, clear descriptions.

They could be rephrased—where ultimately harm is avoided could give the sense; but ultimately might be taken as eventually, i.e., a drawn-out process without any time constraint. Last minute removes any ambiguity.

Sometimes—as above—authors enclose metaphorical expressions in inverted commas. It is usually not necessary, but last-minute concession might then need the hyphen to avoid misunderstanding as a last, minute concession, a misunderstanding unlikely to happen with last minute choices.

Eleventh hour is less prevalent, but “At the eleventh hour, the invitation to speak was withdrawn…”, “At the eleventh hour, bishops continue to launch concerns…”, and “…every 2 hours and 30 minutes until the eleventh hour”—the only literal eleventh hour that I found. Last minute is an obvious metaphor; no doubt somebody was the first to use it, but it’s unlikely that it was recorded. Eleventh hour is not so obvious, and, according to the Oxford English Dictionary, is an allusion to the parable of the labourers (The Book of Matthew, chapter 20).

Last ditch is more to do with effort than time, has military connotations, and is often linked with futility: “with ‘last ditch’ efforts of resuscitation”, “First introduced as ‘last ditch’ therapy in the most critically ill”, “…such ‘last ditch surgery’ invariably fails”. Like last minute and eleventh hour, it is a useful metaphor, although prone to overuse by groups lobbying for expensive treatments. I did find one, not strictly medical, literal use, in an article about the treatment of waste water: “The content of heavy metals in suspended solids decreased along the course of treatment…, through the first ditch to the last ditch.” Unfortunately, metals were also found in subsequent ditches, so the last ditch failed.

Neville Goodman is a retired consultant anaesthetist and a writer. He is co-author of a book on medical English.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that my only competing interest is my co-authorship of a book about medical English.