and suggests that exhaustion from a long and burdensome treatment history is the main reason for refusing treatment. Some psychiatrists recognize the relevance of treatment fatigue and therefore accept refusal of certain treatments when establishing IPS. The psychiatrists also report other challenges. For one, psychiatrists mention that patients who request PAD typically suffer from complex psychiatric disorders with complaints in several domains that defy our current diagnostic models. This makes the application of specific treatment guidelines challenging when establishing IPS. Also, psychiatrists find it hard to assess the quality of past treatments, especially when this concerns psychotherapy. Finally, acceptance-based treatments, which do not necessarily focus on reducing the symptoms but more on accepting them, present a challenge: some psychiatrists reasoned that it is always possible to keep working on acceptance, therefore psychiatric suffering can never be irremediable, but most find this an unreasonable view. So, in answer to the second research question, two main challenges stand out when combining insights from literature and clinical practice. First, uncertainty due to the complicated nature of psychiatric suffering and treatment is consistently shown to be a challenge. Second, treatment refusal, whether or not due to treatment fatigue, is seen as a relevant challenge. Apart from identifying these challenges, it appears that adopting a more retrospective view of irremediability can be a way to address them. Criteria for irremediability The third research question is: what are suitable criteria for establishing irremediable psychiatric suffering in the context of physician assisted death? We answered this question by performing a two round Delphi-study, which is described in chapter 6. Based on the earlier studies and steering group discussions we suggested a first set of criteria for IPS in the context of PAD. We then asked 67 psychiatrists from the Netherlands and Belgium with experience in establishing IPS in the context of PAD if they agreed or disagreed with these using Likert scales. We also encouraged the participants to give their own definition of IPS and to comment on their answers. The results of round one formed the basis for discussions in the project-group and a second round with adjusted and new criteria was drafted. In the end, thirteen criteria reached consensus (Table 1). In general, the participants agree that a carefully posed diagnosis, confirmed by an independent psychiatrist, is necessary. Regarding treatment, there is consensus that the indicated psychopharmacological, psychotherapeutic, recovery-oriented and electroconvulsion treatments have to have been tried and failed. Also, substantial efforts should have been made to improve the patient’s social situation. The participants also agree that the suffering must be present for several years so that all relevant treatments can be tried, but on the other 120 | CHAPTER 7 7