7th November, 2023

How Do You Say No When Someone Might Die?

With Rachel Morris

Dr Rachel Morris

Listen to this episode

On this episode

Saying no and setting boundaries are core to avoiding burnout. But if saying no might put a patient at harm – or worse – what can you do?

In this quick dip episode, Rachel explains the concept of core and flex boundaries along with core and flex consequences. Core boundaries are non-negotiables that we always enforce, rather than preferences we’d like to enforce but can be flexible around.Key to this approach is also recognising the short- and long-term consequences of saying no.

By not setting boundaries or saying no when we need to, we risk damaging our relationships and neglecting our own needs. This can lead to regret, unfulfilled goals, and negative effects on other people who rely on us. But by setting rigid and flexible boundaries, we can get closer to a healthy work-life balance, and keep our priorities and commitments in tact.

Show links

Reasons to listen

  • To discover how to set boundaries and say no in challenging situations, ie when someone’s life might be at stake.
  • To understand the concept of core and flex boundaries and how they can help in decision-making.
  • To learn about the short-term and long-term consequences of setting boundaries and saying no, and the importance of considering them when making decisions.

Episode highlights


Introducing core and flex boundaries


Core boundaries


Flex boundaries


What happens when core boundaries are in conflict


Short-term consequences


Long-term consequences


Core and flex consequences


Hierarchy of boundaries


Putting this into practice

Episode transcript

[00:00:00] Rachel: I was speaking at a conference for medical students the other day. And the talk I was giving was the talk I’ve been doing a lot all around the country about how to say now, embrace your limits, prioritize, set, boundaries, and deal with pushback.

[00:00:14] And in this talk I asked three main questions. Number one is how do we make a choice when it feels like there is none? How do we embrace our limits in that system which is limitless? And the final question is how do we say no? When someone might die?

[00:00:31] And this question has really intrigued me. And when I do this talk, whether it be live at conference or online in a webinar, I always do this pole and that pole is What stops you saying no?. Is it because it’s going to cause severe patient harm? Is it because you feel bad about letting other people down or dumping on your colleagues? Is it because you don’t want to cause other people in convenience? Or is it because you fear, you might upset somebody? Or is it that you’re worried about what other people might think of you.

[00:01:06] Now it’s interesting. When I did this poll with the medical students, I would say 50 or 60% of them. Put their hands up to. I don’t think I’m going to be able to say no in the future because of severe patient harm, because someone might die, because it might really affect patient care.

[00:01:24] Now, interestingly, they were a group of GPS and other clinicians sitting in the front row. Less than 20% of them put their hand up to actually it’s because it’s going to cause severe patient harm. And that has been my experience in doing this talk at various conference for doctors and other healthcare professionals and also webinars online. It’s never more than 20% of people who are practicing say that the main thing that’s stopping them. Is it somebody might die or it might cause a severe patient harm.

[00:01:55] We worry about patient harms. Don’t we be worried about affecting our clients, our customers, our service users, and nobody wants cause patient harm. In fact, absolutely. We should always make the care of our patients and the safety of our patient our priority. But I’d observed just like in that poll, that the, mostly the reason we fail to say no and set boundaries is not because it’s going to cause patient harm. It’s for something else. And so when we ask the question How do I say no? When someone might die? I say to people, we just asking the wrong question. The question isn’t How do I say no when someone might die? Because that actually rarely happens. And if you’re going to say no and someone might die, then do something different. You have the choice, you have the choice about whether at that point you let your boundaries crumble, you change your mind, you do that thing. In order that the patient is safe in order that nobody is harmed.

[00:02:57] So instead of the question, how do I say no when someone might die? We need to be asking ourselves, how do I deal with perfectionism, guilt, people pleasing, pushed back and my own internal dialogue and feelings when I have to say no.

[00:03:43] And we’ve talked about this a lot on this podcast about why we find it difficult to say now about these stories of guilt and shame and fear that go through our heads because we’re constantly catastrophizing and making up stories that it’s going to be really bad in the future. And our threat detection system is activated and all those things.

[00:04:06] But today. I just want to talk about core and flex boundaries and core and flex consequences. Because as that poll showed, when we try and set a boundary, there are consequences and we worry about what happens. And therefore we find it difficult to say no, because I for one never wants to be seen to be dumping on my colleagues. That always seems to be a fate where said that I want people to think really well of me. Of course I do. Of course, we also, and that is normal.

[00:04:38] But I think that if we start to categorize our boundaries and categorize our consequences, then we’ll find it a little bit easier to make the decision about what to I say no to. And is it okay to say no? And how can I tolerate saying no?

[00:04:55] And someone shared with me a very interesting concept about boundaries. This was all about the difference between core boundaries and flex boundaries. Now core boundaries are boundaries, which you will always Inforce unless it’s an absolute emergency. So I wonder what core boundaries you have. Some of my core boundaries are that I always wants to be present on my children’s birthday, that I always wants to be there for our wedding anniversary and make sure that I’m spending time with my other half. A core boundary for me would be the, if any of my immediate family are in trouble, are really ill, I do drop stuff and I go and help them. Another cool boundary for me is that if I have committed to giving a talk or a training session, I turn up and I do that. I don’t let people down.

[00:05:49] Now it’s interesting. I actually had difficulty thinking about actually, what is my core boundary? Because core boundaries should be things that you will not flex, that actually they are set in stone. Because if you start to flex your core boundaries, then it just seems like you’re a bit flaky and you have sort of no moral integrity and you haven’t actually committed to anything. So core boundaries are things that you don’t flex. And you’ll probably find you’ve got a lot fewer core boundaries than anything else.

[00:06:21] But I have trouble actually thinking about what my core boundaries were. Because my problem is I just flex on too many things. So let’s look at flex boundaries. So flex boundaries are boundaries that you set, which is sort of nice to have, which are things that you would prefer. So it’s things like, and when I was writing my things down, I came up with, well, actually I would love to be able to get seven or eight hours of sleep a night. So one of my flex boundaries is gains a bed at a decent time. One of my flex boundaries says I would like to do some form of exercise on most days. That’s really important to me. Another flex boundary is I will take one day a week as my mop-up day in which I will always meet my friends for coffee, do some exercise, and try and rest. Now that is a flex boundary because sometimes it doesn’t happen. Because sometimes there’s a conference on the day that is my day off. And that conference is set in stone and I would like to go and speak at it. So I will flex that boundary. I’ll also flex the sleep boundary when I want to go and have a night out with my friends.

[00:07:28] So you can see how some of our flex boundaries, yeah, they’re there to be flexible. And I’m sure you can think of a lot more flex boundaries in such as I will always have a lunch break. I will try and take a 10, 15 minute break in the middle of the morning on the middle of the afternoon. Or I will return from work at a certain time. Now, if you have small children in, in childcare, then you’ll have a core boundary about, I will always get there at that time to pick them up. But if like me, you’ve got teenagers, um, and you want to be home at a certain time, but it doesn’t always happen, that’s okay, that is a flex boundary. And we can choose what we flex, can’t we?

[00:08:08] The problem with flex boundaries is if we start to Inforce them and have no flexibility, we can seem to be a bit intransigent, a bit in flexible. So core boundaries we need to stick to, and if we don’t stick to them, we seem a bit flaky. Flex boundaries are ones that we would really like to enforce, but there is some flex around that. It’s okay to flex those a little bit.

[00:08:36] Now of course, without core boundaries, there’s always going to be times. When you don’t seem it. So for example, if one of my family was incredibly ill, then of course I’ve had canceled a training session or a webinar to go to the hospital and thought that’s out. Of course I would. But the problem that a lot of us make is that we start to think of our core boundaries as slightly flexible.

[00:09:01] Now the question is, will I ever flex my core boundaries? Well, yes, occasionally I will. If I’m down to do a training session, and one of my family has an accident. Of course, I’ll go off and I’ll deal with that and I’ll have to cancel stuff. Life happens, but it’s helpful to be mindful of the fact that the problem occurs when we start to flex our core boundaries and we start to not flex our flex boundaries.

[00:09:26] The other side of the coin is consequences. And thinking about actually, what might happen if I don’t enforce this boundary, but if I do enforce this boundary and say, no, So for me, some of the red flag consequences, some of the consequences that I won’t tolerate and I will flex any boundary in order for that not to happen is patient harm. You know, if someone’s going to die. I will do something different, I won’t enforce my boundaries. If it means a loss of integrity or honesty, then, then, then I won’t do that thing. If it means. I guess I’m going to lose my job, I wait and see that either. But there are very few actual red flag boundaries. It’s mainly around honesty and causing harm to other people. Also trauma, if something’s going to cause trauma or severe hurts somebody else, that is a red flag for me and, and I won’t do that.

[00:10:24] And I do remember a time when I was an SHO.. I was a trainee, and, uh, we had really quite a sick patient and I asked a more senior person who wasn’t on my team for some help. And they said no. They said no, and I still remember to this day, how that felt. Not to be given help in an emergency situation when I really needed them. And that’s been, that’s been quite traumatic and I never want that to happen to anybody else. But let me say this was a severe emergency. It was in the context of a patient being really, really very sick and unwell. So that is a severe harm thing that this person said no to because they were trying to enforce some, some flexible boundaries about not helping someone on another team without a consultant referral, it was absolutely ludicrous.

[00:11:18] So there’s a red flag consequences, but there are two other types of consequences that we can predict probably it’s going to happen when we enforce them boundaries. And we say no. And these are the long-term consequences and the short term consequences.

[00:11:34] And I like to think of the short-term consequences as being the tolerable consequences. Now at the time they actually feel incredibly scary. And these are the ones that we shy away from because of our amygdala reaction, which we’ve talked about in other episodes. So check out the amygdala hijack episodes.

[00:11:55] But these shorts had consequences of saying no. Of setting boundaries of enforcing our core or our flex boundaries are things like feeling guilty, somebody not liking the fact that we’ve said no, somebody else being inconvenienced, maybe I miss out on an opportunity. There’s some FOMO going on. It might be that somebody upsets or put out and I might feel awkward. Embarrassed, guilty, ashamed, all those things that when I say no to people crop up for me. These are short-term consequences that I don’t like, but I can tolerate, and that is not going to kill me.

[00:12:34] And the thing we get so wrong about this category of consequences is that we confuse it with the next category of consequences, which the longterm consequences. And this is something we absolutely neglect. We think about the red flag consequences, and we think about the short-term consequences, and we don’t look at the longterm consequences.

[00:12:55] And what are the longterm consequences of not setting boundaries? Well, If we fail to say no, the long-term consequences are burnout. Going off sick, not being able to say my job and perhaps. Leaving our profession early, and not being able to fulfill up attentional T what we wanted to do. The longterm consequences of failing to say no, or set boundaries could be the, our relationships suffer. Our relationships with our families, with our partners when we never managed to spend any time with them and we’re constantly distracted or working. We end up with health problems, physical, mental, emotional problems if we don’t set boundaries and say no, because we end up ignoring our own needs, we end up disappointing ourselves. And that lovely quote I had on Glennon Doyle podcast was. If there’s a choice between disappointing someone else and since appointing yourself, disappoint someone else every time, because if you disappoint yourself that will lead to regret. That will lead to regret of not doing that thing you wanted to do. Failing to make the changes you want to failing to put the boundaries out, which mean that you can focus on the really important things in life, which a lot of them are out of work. A lot of them. Our to do with the wellbeing factors, such as connection, noticing, being present. Learning stuff.

[00:14:24] And then the other long-term consequence that we forget about is the effects on other people. If we fail to set boundaries, if we fail to say no, then we fail to help anyone else change their behavior. We failed to help anyone else actually take responsibility for their own behavior, recognize what isn’t working, and we do not give them the opportunity to change.

[00:14:48] And we need to be careful here. We need to stay in our own state and a power. You know, I can’t change anybody else. I can only change myself. butts, if I put some boundaries up, then the other person will experience the consequences, not me, and that will mean that they start to change their behavior. So you can see this individually, you know, with someone being allowed, just to, I don’t know, overspend and overspend and parents bailing them out the whole time, they never learned to manage their money. We can see this in groups when the manager or the leader is constantly just taking over the work for people because they haven’t planned properly and they don’t bear the consequences of not eating any deadlines. And you see this in services where when we fail to say no to stuff, we constantly absorbed the extra work and consequently, they don’t see the needs of recruit anyone else to increase funding to the service or provide any more resources because we’re killing ourselves doing it.

[00:15:43] So these long-term consequences are severe. But we never think of them and we never worry about them as much as we worry about the short-term consequences, the short-term consequences, which feel intolerable and difficult at the time.

[00:15:59] So as well as your core and flex boundaries, I wonder whether we also need to have core and flex consequences. Our core consequences that we want to avoid at all costs are definitely those red flag things. We want to avoid patient harm, we want to avoid traumatizing other people, and we want to avoid doing anything that has a probity issue attached to it, that’s not honest. That’s not in my own integrity.

[00:16:25] And then the flex consequences, will those are the short-term consequences. You know, the things that actually I can flex these consequences. It’s okay if someone’s upset with me or it’s a little bit inconvenient to them, I need to learn to tolerate those, but quite often we see these flex consequences as core consequences, and those are things that we must never tolerate, and we will always do something different. Actually with the flexible consequences, we can choose what we do. Because they are not so severe, they are not going to kill you. They’re not going to be problematic in the long term.

[00:16:59] The problem I see is when we start to treat the long-term consequences as something that’s flexible, rather than keeping them as core consequences. Because, you know, burnout happens in the future, health problems happen in the future, but unless we start to address that now, It’s pretty inevitable. And one question that we fail to ask ourselves constantly is what are the consequences if nothing changes, or if this behavior continues, if I keep saying yes? We focus on the short-term consequences but not on the longterm consequences. And these long-term consequences should be core consequences that are in the same category as the red flag consequences which you won’t tolerate. And so if you tolerate those sort of consequences, you’ll be flaky, and if you don’t tolerate the short-term consequences, you’ll be a bit inflexible. Can you see how there’s a bit of a parallel with the boundary stuff with the core and the flex boundaries?

[00:17:59] So that got me thinking. Is there a hierarchy for these consequences and for these boundaries? And I think probably yes there is. I mean, we know that the core consequences, the patient harm and the integrity stuff is so, so important. I’d probably say that pretty much trumps anything. It will trump most of our core boundaries, apart from maybe if one of our family members is incredibly sick and we’re called away to an accident or something like that. But really your red flag, your core consequences will always trump your decision-making in anything else.

[00:18:37] But then what should the order be? Well, I think. If you think about consequences, these long-term consequences, those must always, always trump the short-term consequences. So you think about, actually what are my boundaries here? I should be able to put in my flex boundaries, I should be able to put in my core boundaries so that we get these good long-term consequences. And these flexible consequences of somebody being upset with me, well, that goes right to the bottom. If it’s a choice, again, I’m going to set between disappointing yourself or other people, you disappoint other people every time.

[00:19:20] So your flexible boundaries, actually, you should be enforcing them if they’re just going to be causing flexible consequences, right? That’s fine, because we can tolerate the short-term consequences. Likewise our core boundaries, we will always be enforcing, but sometimes some of the core consequences might trump that.

[00:19:40] So how can we actually apply this practically? Well, I suggest you just make a few lists. What your core boundaries? What are the things that you will always Inforce and pretty much you will never flex them unless one of the red flag consequences trumps that?. But what are your flexible boundaries? The boundaries, which, you know, you really do need to have, because if you don’t have those boundaries, the long-term consequences are going to be bad. But actually you can hold those flexible boundaries over and above those short-term consequences, which you can tolerate. So write a list of your flexible boundaries and. In my experience, most of us have no idea what our non-negotiables are or what our preferred boundaries are.

[00:20:29] And then you might also want to make another less, which of your red flag consequences, those things that will pretty much trump everything else, but of your long-term consequences and your short-term consequences, what are the longterm consequences that you want to avoid? And you will find that by enforcing your flexible boundaries, you will avoid those long-term consequences. And those short-term things that just feel so difficult at the time, we need to work on how we can start to tolerate these short term consequences that make us feel dreadful, but actually, this is the key to saying resilience, sustain productive, to being in it for the long haul.

[00:21:13] And you might need to look at what you need to do. To be able to tolerate some of these short term, not so severe consequences, more. You might need to get some therapy. You might need to read a few books about how to let these thoughts go about how to change the stories in your head. And in the CPD workbook for this quick dip episode, we will put a table for you to fill in. So just download that and it will be all there so that you can fill that in and reflect on the questions that we’ve given you.

[00:21:43] And we have loads and loads of resources that will help you such as the Beat Stress and Thrive course or our Shapes Academy program. So do check out some of the resources on the website, get the help you need and get really clear about your core boundaries, your flex boundaries, your red flag consequences, your short-term consequences, and your longterm consequences.