file, consider the reputation of the center where the patient was treated and take into account the patient’s views on past therapies (table 3, quote 3). When evaluating past attempts to reduce suffering, participants regard the relevant treatment guidelines as important resources (table 3, quote 4). Participants also emphasize the value of interventions that try to diminish suffering by altering the patient’s perception of the complaints. Acceptance and commitment therapy is often mentioned in this context, but participants also refer to recovery-based or rehabilitation-based approaches or ‘using the handicap model’ (table 3, quote 5). Based on this view of psychiatric treatment, some participants argue that the options are practically endless. Therefore, irremediability cannot be established (table 3, quote 6). In contrast, other participants feel that endlessly working towards acceptance or recovery is not a reasonable answer to a patient’s request for PAD (table 3, quote 7). Various participants noticed ‘treatment fatigue’ when discussing new treatment options with patients. The participants suggest that this fatigue may be due to the typically long treatment history of patients requesting PAD (table 3, quote 8). Sometimes, within the current legal framework, additional treatment is necessary in order to be eligible for PAD. As a result, patients may try a treatment just to ‘check the box’. Various participants doubt whether treating unmotivated patients under these conditions is effective, especially when it concerns psychotherapy. Participants mention that there is no research available about the efficacy of treatment with unmotivated patients (table 3, quote 9). One participant emphasizes that there are also cases where the possibility of PAD can increase treatment motivation (table 3, quote 10). A final challenge regarding treatment is refusal of new treatments by the patient. Many participants try to determine whether the refusal is reasonable. If not, they will not see suffering as irremediable, and stop the PAD-review-procedure (table 3, quote 11). Several participants conceptualize reasonability in terms of a balance between burden and possible benefit. The treatment history is also relevant (table 3, quote 12). 84 | PART II - CHAPTER 5 5