results show that most PPD who have received PAD suffer from complex disorders for which they have been treated unsuccessfully for a very long time. Also, the casefiles show that in four cases psychiatrists disagreed about irremediability. Remarkably, in the casefile summaries included in this study, the consulted psychiatrists agreed on all other requirements, such as mental capacity or unbearableness. This finding suggests that irremediability is the PAD-criterium yielding the highest rate of interpretive differences when applied to psychiatric suffering, suggesting that establishing IPS is challenging for practitioners. In order to get more insight in the challenges of establishing IPS in the context of PAD we performed a scoping review, synthesizing the insights of 50 articles that address this issue. This study is described in chapter 4. The literature is mainly conceptual and normative, but also eight empirical studies are included. Three core issues emerge, the first one being the issue of uncertainty. Due to the nature of psychiatric disorders and psychiatric treatment, uncertainty about irremediability is seen by most as unavoidable. The challenge lies in the dissensus about the level of certainty that is necessary before irremediability can be established. A second important theme is hope. Various authors argue that the possibility of PAD may lead to hopelessness. Other authors adopt an opposite view and argue that it is the experience of irremediability that causes hopelessness and that the option of PAD can actually help. A third theme in the literature is treatment refusal. Empirical studies show that PPD who request PAD have regularly refused certain treatments. How to respond to these refusals and what this implies for the assessment of irremediability of the suffering in the context of PAD is seen as an important challenge. The insights gained in the scoping review formed the basis for the qualitative study in chapter 5. For this study we interviewed eleven psychiatrists with experience in assessing IPS in the context of PAD. The participants confirm that they feel uncertain while deciding on irremediability. According to participants, the complicated nature of psychiatric suffering makes meaningful prognostic claims problematic, since most patients suffer from complex disorders with complaints in several domains that defy current diagnostic models. Participants also find it difficult to assess the quality of past treatments, especially psychotherapy. Participants address this challenge by focusing on past attempts to reduce the suffering that have been tried and failed. This retrospective assessment of irremediability is frustrated when a patient refuses certain treatments, which various participants therefore also recognize as a relevant challenge when establishing IPS. At the same time, different participants also recognize ‘treatment fatigue’ as a separate cause of suffering in patients seeking PAD, which also hampers treatment motivation. Different participants find this understandable, moving them to accept refusal of certain treatments when establishing IPS. For instance, when SUMMARY | 137 A
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