decision about irremediability solely with the experts is problematic because the, sometimes unconscious, biases of the physician can influence the decision-making process. It also seems unduly paternalistic, especially when the patient is competent to decide on the treatment at hand. The third approach is that the patient decides about the irremediability of suffering. According to this approach, the patient is best suited to weigh the harms and benefits of pursuing further treatment and to incorporate this choice into their life story and personal values. Indeed, in most of the western world, if a patient chooses to stop pursuing remedies for their suffering, this is their right. In the end-of-life context, the viewpoint that only the individual can decide ‘when enough is enough’, is represented by different special interest groups, such as the ‘cooperation last will’ in the Netherlands, ‘death with dignity’ in the United States or ‘my death my decision’ in the United Kingdom, arguing for progressive patient-centered end-of-life laws. The Canadian physician assisted death law reflects this view and demands that ‘only treatments that are acceptable to the patient have to be tried and failed’. The problem with this view is that, especially when the suffering is caused by illness, it can be difficult to make an informed decision without the guidance of a medical professional. Medicine can be complicated, therefore training and experience are often needed to weigh the different options. Also, suffering can cloud judgment and may sometimes lead to irrational health believes or cognitive distortions. (Dembo, van Veen & Widdershoven, 2020) The fourth approach, that of shared decision-making, is the one that we have put forward throughout this dissertation. A meaningful dialogue between patient and expert can mitigate some of the identified challenges, such as uncertainty and treatment refusal. A shared approach to establishing irremediability integrates all the relevant sources of knowledge. The psychiatrist can synthesize all sources that are accessible to an expert, among which the information from the independent 2nd opinion, and the patient can use their lived experience to apply this information to their unique situation. By synthesizing these sources of knowledge, uncertainty is minimized. Through dialogue, the patient and psychiatrist can also weigh whether the benefits of further treatment outweigh the harms, making a balanced decision about treatment refusal possible. In medicine, shared decision making is widely seen as the optimal approach to making health care decisions and throughout this dissertation we have not come across compelling arguments why establishing irremediability in the context of PAD should differ. (Shay & Lafata, 2015) This does not mean that the process of shared decision making is without challenges in the context of PAD. First, in regular medical practice, it is the patient who has the final decision. In PAD however it is the physician that ultimately decides, based on dialogue with the patient. This GENERAL DISCUSSION | 123 7