hand they agreed that there are limits to the number of diagnostic procedures and treatments a patient has to undergo, before IPS can be established. The criteria that did not reach consensus are also worth mentioning. For instance, dissensus remained regarding structured psychodiagnostic testing. Furthermore, the participants did not agree whether acceptance-based psychotherapy or psychosurgery treatments should be tried if indicated. In answer to the third research question, we can say that it is possible for a group of experts to reach consensus about some essential criteria for IPS. In essence the experts agree that a sound psychiatric diagnosis should be present and substantial biopsychosocial treatment should have been tried for several years. TABLE 1. Consensus criteria for irremediable psychiatric suffering in the context of physician assisted death Diagnostic criteria A. When establishing irremediable psychiatric suffering: 1. A psychiatric disorder, as described in the DSM-5, should be established according to applicable guidelines. 2. In addition to the classification according to the DSM-5, a narrative account must be given that includes etiology and pathogenesis. 3. In addition to the descriptive diagnostics according to the DSM-5, it should be standard practice to verify whether there are contextual or systemic factors that cause or maintain the psychiatric complaints. B. During the PAD-procedure, the diagnosis must be independently confirmed by at least two psychiatrists. C. There are limits to the number of new diagnostic procedures a patient must undertake before it can be said that the psychiatric suffering is irremediable. For example: a patient or psychiatrist may refrain from further diagnostic procedures on reasonable grounds, such as a long history of illness and treatment. Treatment criteria D. If side effects allowed, the indicated drug-treatments should have been adequately performed without leading to a significant reduction in suffering. E. If side effects allowed and if indicated, electroconvulsive therapy (ECT) should have been attempted for a sufficient length of time without leading to a significant reduction in suffering. F. Psychotherapeutic treatments indicated by the applicable guideline must have been attempted without leading to a significant reduction in suffering. G. If there are indications that entering into a repeated psychotherapeutic trajectory is meaningful, this must be offered before irremediable psychiatric suffering can be established. For example: because conditions were sub-optimal in previous therapy. H. At least one recovery-oriented treatment must have been attempted without leading to a significant reduction in suffering. I. If necessary, substantial efforts should have been made to improve the patient’s social situation without leading to a significant reduction in suffering. J. Because all reasonable treatments must be tried, the psychiatric suffering must have been present for several years before irremediable psychiatric suffering can be established. K. There are limits to the number of treatments a patient must undergo before psychiatric suffering can be considered irremediable. For example, a patient or psychiatrist may refrain from further treatment on reasonable grounds, such as a long history of illness and treatment or the prospect of serious side effects. GENERAL DISCUSSION | 121 7
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