Breaking Bad News · Advanced · Ethics

Fever and Abdominal Distension Post-Operatively

Practise this PLAB 2 breaking bad news station on Post-Operative Anastomotic Leak. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on the vascular surgery ward. Mrs Violet Parry underwent an abdominal aortic aneurysm repair three days ago. She has developed signs of anastomotic leak with subsequent peritonitis and sepsis. Her condition is deteriorating despite maximum support. The surgical consultant has reviewed Mrs Parry and asked you to speak with her husband David, as you have been involved in her post-operative care and have built a rapport with the family. Mrs Violet Parry underwent an abdominal aortic aneurysm repair three days ago. She has developed signs of anastomotic leak with subsequent peritonitis and sepsis. Her condition is deteriorating despite maximum support. You must inform her husband, David, of this life-threatening complication and discuss what happens next.

Background notes: PMH: Hypertension (well-controlled), Hypercholesterolaemia (well-controlled), Abdominal aortic aneurysm (post-operative day 3 from repair)

What this station tests

  • Duty of candour: open and honest disclosure of a complication, whether or not there was error
  • Explaining anastomotic leak in plain language: the join has leaked, causing infection
  • Honest prognosis including the possibility of death: 'yes, this is a possibility'
  • Not being defensive: the complication is recognised, not necessarily an error
  • Regular updates: silence increases family anxiety, even 'no change' updates are valuable

How to use your 8 minutes

  • 0-1 min — Setting: Introduce yourself. Ensure privacy. Ask what they already know (SPIKES: Perception).
  • 1-2 min — Warning Shot: Give a warning shot. 'I'm afraid I have some difficult news.' Pause and allow reaction.
  • 2-4 min — Deliver Information: Give information in small chunks. Use clear, simple language. Avoid euphemisms. Pause after key information.
  • 4-6 min — Respond to Emotion: Acknowledge and validate emotions. Allow silence. Empathic statements. Address immediate concerns.
  • 6-8 min — Plan and Support: Discuss next steps when patient is ready. Offer support resources. Arrange follow-up. Written information.

Consultation approach

The opening

Explaining a serious post-operative complication to a patient's spouse requires duty of candour, honesty about what has happened, and a clear management plan. David is the husband of Mrs Violet Parry (68), who had AAA repair 3 days ago and has now developed an anastomotic leak with peritonitis. Open with: 'Mr Parry, I need to update you about Violet. Can we sit down? I am afraid there has been a complication.'

Core approach

Explain what has happened in plain language. 'Three days after Violet's operation, she has developed a complication where the join in the blood vessel has leaked. This has caused infection in her abdomen, which is making her very unwell.' Be honest about severity: 'This is a serious complication. She is critically ill and needs emergency surgery to repair the leak.'

Duty of candour: 'I want to be completely open with you about what has happened. This is a recognised complication of this type of surgery. It does not mean anything was done wrong during the operation, but it is serious and we are treating it as an emergency.'

He will ask about prognosis. Be honest: 'The emergency surgery carries significant risk at her age and with this level of infection. The surgical team will do everything they can.' If he asks whether she could die: 'Yes, this is a possibility, and I want to be honest with you about that. But we are acting quickly to give her the best chance.'

Closing and safety netting

Explain next steps. Emergency return to theatre. ICU post-operatively. He may want to see her before surgery. Involve the consultant surgeon to discuss the surgical plan and risks. 'Do you have any questions for me, or would you like to speak to the consultant who will be performing the surgery?'

Practical support: he can stay in the hospital. Chaplaincy if desired. Keep him updated regularly (even if nothing has changed, silence increases anxiety). 'I will come back to update you as soon as the surgery is finished.' Incident documentation per duty of candour.

How examiners mark this station

Examiners will focus heavily on Domain 3 (Interpersonal Skills): how sensitively you deliver the news, whether you give a warning shot, allow silence, and respond to emotion. Domain 2 (Clinical Management) assesses the accuracy and clarity of information provided and the appropriateness of the plan discussed. Domain 1 (Data Gathering) assesses whether you established prior knowledge and readiness.

Domain 1 (Supporting)

Scores well: Complication explained clearly. Severity conveyed. Family understanding checked.

Costs marks: Not explaining clearly. Minimising severity.

Domain 2 (Primary focus)

Scores well: Emergency surgery explained. ICU plan. Duty of candour documented. Consultant involvement. Regular updates promised.

Costs marks: Not explaining the plan. No duty of candour. No consultant access.

Domain 3 (Primary focus)

Scores well: Honest without brutal. Allowing emotion. Offering to see her before surgery. Genuine compassion. Regular updates. Not being defensive.

Costs marks: Defensive. Evasive. Not allowing emotion. Leaving him without updates.

Common examiner feedback (and how to fix it)

Did not demonstrate sensitivity when delivering difficult information

Fix: Always give a warning shot. Deliver the key information in one clear sentence, then stop. Allow silence. Respond to emotion before giving more detail.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: After delivering bad news, your primary role shifts to emotional support. Use the NURSE mnemonic (Name, Understand, Respect, Support, Explore) to respond to the patient's reaction.

Common mistakes in this station

  1. Being defensive or evasive: duty of candour requires openness, not defensiveness
  2. Minimising the severity: she is critically ill and he needs to know
  3. Not allowing him to see her before surgery: he may want to, and this should be facilitated
  4. Not involving the consultant surgeon: the family should have access to the operating surgeon

Resitting PLAB 2?

If breaking bad news stations have been a weakness, practise the SPIKES framework until the structure is automatic. The most common resitter mistake is rushing past the emotional response. Allow genuine silence after delivering the news, and resist the urge to fill pauses with more information.

Example opening

Hello, my name is Dr [Name]. Thank you for coming in today. Before we start, can I ask if you have anyone with you, or would you like to have someone here? I have the results from your recent tests, and I'd like to go through them with you.

Frequently asked questions

How should I break the news in this post-Operative anastomotic leak station?

Explaining a serious post-operative complication to a patient's spouse requires duty of candour, honesty about what has happened, and a clear management plan. David is the husband of Mrs Violet Parry (68), who had AAA repair 3 days ago and has now developed an anastomotic leak with peritonitis. Open with: 'Mr Parry, I need to update you about Violet.

Where are marks won and lost in this post-Operative anastomotic leak station?

Examiners reward: Complication explained clearly. Severity conveyed. Family understanding checked. Candidates are penalised for: Not explaining clearly. Minimising severity.

Where do candidates most often go wrong in this station?

Being defensive or evasive: duty of candour requires openness, not defensiveness. Another frequent error: Minimising the severity: she is critically ill and he needs to know.

Can I do well in this station without real-world experience of post-Operative anastomotic leak?

This station rewards process over personal experience. The skill being assessed: Explaining anastomotic leak in plain language: the join has leaked, causing infection. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

Related cases