because patients will often die from these diseases unassisted. (Table 2, quote 4). A consequence of this uncertainty is that it leaves room for substantial interprofessional differences (Table 2, quote 5). Another participant, however, argues that uncertainty should be accepted. (Table 2, quote 6). TABLE 2. Quotes on the definition of IPS # Quote 1 “When someone says: I have a chronic disorder that will not go away, when all the experts agree and when it causes suffering, then the suffering is irremediable” - P6 2 “We all know examples of people with, for example, therapy-resistant depression, which we have more or less given up (...) and then a few years later you find out to your surprise that they have found their way and have recovered. That makes [establishing IPS] very difficult.” - P11 3 “If someone has gone through all the [treatments] and there is nothing left of which you can say: if you do that, it will be different. (...) Then I think [the suffering] is irremediable.” – P5 4 “I think [in psychiatry] it is very complicated [to establish irremediability], with cancer you just know. Chemotherapy does nothing, there are no other options and then the tumor starts to grow and then… it just stops.” - P2 5 (Hyperbolically) “I think that if the same patient is seen by 10 different psychiatrists, you will get 10 completely different letters [describing the patient and advising on irremediability].” – P7 6 “We just have to accept that there will always be some degree of uncertainty. The moment I, as an independent psychiatrist, say, ‘I think the legal criteria have been met’, then there is an uncertainty. There is a confidence interval around it. (…) Because it concerns a dichotomous choice of life or death, we want absolute 100% certainty. (…) But this is not possible.”- P8 Challenges in establishing IPS In relation to establishing IPS, participants mention challenges regarding diagnosis and treatment. Challenges regarding diagnosis Participants say that patients who request PAD are often diagnosed with more than one psychiatric disorder, which complicates the assessment procedure and the application of evidence-based guidelines. One participant argues that, therefore, a second opinion by an all-round psychiatrist is the best way to determine IPS (table 3, quote 1). It may also occur that the independent psychiatrist comes to a different diagnosis in the course of the PAD procedure, often leading to new treatment options. One psychiatrist describes a patient he diagnosed with a new disorder, but also nuanced the accuracy and clinical importance of these new diagnostic insights (table 3, quote 2). Challenges regarding treatment Most challenges in establishing IPS are related to treatment. For instance, it may be challenging to assess the quality of past treatments, especially when they concern psychotherapy. In order to evaluate past treatments, participants review the patient’s A QUALITATIVE STUDY ON IRREMEDIABILITY | 83 5