ABSTRACT Background Establishing irremediability of suffering is a central challenge in determining the appropriateness of physician assisted death (PAD) for patients with a psychiatric disorder. The objective of this study is to learn how experienced psychiatrists define irremediable psychiatric suffering (IPS) in the context of PAD and what challenges they face while establishing IPS. Methods In a qualitative study, we performed 11 in-depth interviews with psychiatrists who have experience assessing IPS in the context of PAD. Results Although IPS is, essentially, a prospective concept, when defining it psychiatrists mostly rely on retrospective dimensions, such as a history of failed treatments. When establishing IPS, psychiatrists face diagnosis and treatment challenges. The main challenge regarding diagnosis is that patients requesting PAD are often diagnosed with more than one psychiatric disorder. Important treatment related challenges are: assessing the quality of past treatments, establishing the limits of approaches that aim to alter the patient’s perception, and managing ‘treatment fatigue’ and treatment refusal. Discussion IPS is mostly defined in terms of failed past treatments. Challenges regarding diagnosis and treatment complicate the process of establishing IPS. The finding that most patients are diagnosed with more than one psychiatric disorder calls for a critical appraisal of the due diligence procedure for PAD. In response to the challenges related to treatment, intersubjective clinical criteria for IPS in the context of PAD should be developed. Also, further investigation of the concept of ‘treatment fatigue’ in psychiatry may provide insight into why some patients request PAD. 78 | PART II - CHAPTER 5 5