be attentive to treatment fatigue in current clinical practice, but more research on this topic could also provide new insights and might result in better care for patients with treatment resistant psychiatric disorders. Eventually this may lead to subsidiary alternatives to PAD, such as palliative or recovery-oriented treatments. The participants also mentioned struggling with treatment refusal while establishing IPS. The finding that treatment refusal is a relevant issue is in line with earlier studies, showing that 56% of PPDs that received PAD have refused some form of treatment. (Kim et al., 2016) It also justifies the considerable attention treatment refusal has received in the conceptual literature about IPS in the context of PAD. (van Veen et al., 2020) As mentioned above, from a retrospective view on irremediability, it is reasonable to assert that when a patient refuses a substantial number of treatments, IPS cannot be established, because this hampers the opportunity to properly asses irremediability. In our view, a process of shared decision-making is most suited to decide on the limits of treatment refusal. (Berghmans et al., 2013) The patient should be aware of the potential benefits and burdens of new treatments and the psychiatrist should try to understand why the patient refuses certain treatments. Again, intersubjective clinical criteria for IPS in the context of PAD, could help to establish reasonable limits for treatment refusal. The main limitation of this article is the limited number of psychiatrists interviewed. The main strength of the study is that it adds in-depth empirical knowledge to a controversial topic that is gaining global significance and that is subject of a longlasting conceptual debate. Finally, future research should also focus on the views of psychiatrists from other countries and cultures, as well as patient views on IPS in the context of PAD should be further explored. (Pronk et al., 2021; Verhofstadt, Thienpont, & Peters, 2017) In conclusion, establishing irremediability of suffering is a central challenge in the context of PAD for PPD. We performed 11 in-depth interviews with psychiatrists who have experience assessing IPS in the context of PAD to learn how they define IPS and what challenges they face while establishing IPS. Although IPS essentially is a prospective concept, psychiatrists mostly refer to retrospective dimensions when defining IPS. More specifically, they mainly focus on the history of failed treatments. This means that a retrospective view on IPS might be more suited. When establishing IPS the psychiatrists face challenges related to both diagnosis and treatment. The main challenge regarding diagnosis is that patients requesting PAD are mostly diagnosed with more than one psychiatric disorder. Important treatment related challenges are: assessing the quality of past treatments, establishing the limits of approaches that try to diminish suffering by altering the patient’s perception, and managing treatment 88 | PART II - CHAPTER 5 5
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