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Cited by 22Palliative Care and End-of-Life IssuesEthics and bioethics in healthcarePalliative and Oncologic Care

Irremediable psychiatric suffering in the context of medical assistance in dying: A delphi-study

Open access
van Veen, Sisco M.P., Evans, Natalie, Ruissen, Andrea M., Vandenberghe, Joris, Beekman, Aartjan T.F., Widdershoven, Guy A.M.·2022·The Canadian Journal of Psychiatry
DOI 10.1177/07067437221087052PMC PMC9510999

Published version of a preprint

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Abstract

Objective: Patients with a psychiatric disorder are eligible to request medical assistance in dying (MAID) in a small but growing number of jurisdictions, including the Netherlands and Belgium. In Canada, MAID for mental illness will become possible in 2023. For this request to be granted, most of these jurisdictions demand that the patient is competent in her request, and that the suffering experienced is unbearable and irremediable. Especially the criterion of irremediability is challenging to establish in patients with psychiatric disorders. The aim of this research is to establish what criteria Dutch and Belgian experts agree to be necessary in characterising irremediable psychiatric suffering (IPS) in the context of MAID. Methods: A two-round Delphi procedure among psychiatrists with relevant experience. Results: Thirteen consensus criteria were established: five diagnostic and eight treatment-related criteria. Diagnostically, the participants deem a narrative description and attention to contextual and systemic factors necessary. Also, a mandatory second opinion is required. The criteria concerning treatment show that extensive biopsychosocial treatment is needed, and the suffering must be present for several years. Finally, in the case of refusal, the participants agree that there are limits to the number of diagnostic procedures or treatments a patient must undergo. Conclusions: Consensus was found among a Dutch and Belgian expert group on potential criteria for establishing IPS in the context of MAID. These criteria can be used in clinical decision-making and can inform future procedural demands and research.

AI snapshot

Written from the paper’s full text.

TL;DR

A two-round Delphi study among Dutch and Belgian psychiatrists reached consensus on 13 criteria for establishing irremediable psychiatric suffering (IPS) in the context of medical assistance in dying (MAID). The criteria cover five diagnostic and eight treatment-related requirements, while specific treatment-refusal criteria did not reach consensus.

Key findings

  • After two Delphi rounds, 13 consensus criteria were established: five diagnostic and eight treatment-related criteria.
  • Diagnostic consensus included DSM-5 diagnosis according to guidelines, a narrative account including aetiology and pathogenesis, attention to contextual/systemic factors, independent confirmation by at least two psychiatrists, and limits to the number of new diagnostic procedures.
  • Treatment consensus included adequate indicated drug treatment, ECT if indicated and side effects allow, guideline psychotherapies, at least one recovery-oriented treatment, efforts to improve social situation if necessary, suffering present for several years, and limits to the number of treatments.
  • In round 1, 8 of 20 criteria reached consensus; none of the treatment refusal criteria reached consensus. In round 2, 9 criteria were rated, with consensus on narrative account, limits to diagnostics, suffering for several years, repeated psychotherapy if meaningful, and limits to treatments.

Methods

  • Modified two-round Delphi procedure among psychiatrists with at least five years of clinical experience and experience assessing patients with psychiatric disorders requesting MAID; participants were recruited in the Netherlands and Belgium via project group networks and snowballing.
  • Round 1 included an open definition of IPS and 20 criteria rated on a 5-point Likert scale; consensus was defined as 70% agreeing/strongly agreeing or disagreeing/strongly disagreeing. Comments were thematically analyzed, criteria were modified or rephrased, and round 2 contained nine criteria; no third round was performed due to response stability.
  • Analysis used descriptive statistics (SPSS v25.0), qualitative analysis (Maxqda v18.2.4), CREDES guidelines, and a preregistered protocol (Open Science Framework project code qx5hy). Round 1 was completed by 53 psychiatrists and round 2 by 47.

Limitations

  • Stated: the Delphi questionnaire structure was determined by researchers and participants’ comments were interpreted by the project group, limiting participant influence; no widely accepted benchmark exists for adequate consensus; changing criteria between rounds prevented calculating response-stability; relatively new treatments such as transcranial magnetic stimulation or psychedelic treatments were not included.
  • Evident from the text: the sample was limited to Dutch and Belgian psychiatrists with MAID experience, so generalizability to other jurisdictions and to patient or other stakeholder perspectives is unclear; several round 2 items were accepted as final outcomes without reaching the 70% consensus threshold (e.g., psychosurgery 62% agree/strongly agree, acceptance-oriented psychotherapy 66%, prognosis based on past treatment failure 66%), leaving interpretive room.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1177/07067437221087052

Cites

22 of 22 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 20 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The expert panel reached consensus that there are limits to the number of treatments a patient must undergo before psychiatric suffering can be considered irremediable.

    “There are limits to the number of treatments a patient must undergo before psychiatric suffering can be considered irremediable. For example, a patient or psychiatrist may refrain from further treatment on reasonable grounds, such as a long history of illness and treatment or the prospect of serious side effects.”
    Quote in the paperSubstantial claim
  • Findingreasoning

    None of the treatment refusal criteria reached consensus.

    “None of the treatment refusal criteria reached consensus.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Of the eight initial treatment criteria, five reached consensus in the first round.

    “Of the eight initial treatment criteria, five reached consensus in the first round (Table 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Through a modified Delphi method, 13 expert consensus criteria for IPS in the context of MAID were identified, regarding diagnosis and treatment.

    “Through a modified Delphi method, 13 expert consensus criteria for IPS in the context of MAID were identified, regarding diagnosis and treatment.”
    Quote in the paperSubstantial claim
  • Findingnone given

    The expert panel reached consensus that at least one recovery-oriented treatment must have been attempted without leading to a significant reduction in suffering.

    “At least one recovery-oriented treatment must have been attempted without leading to a significant reduction in suffering.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 52
  • The quote only partly states this claim. 1
  • May combine two claims. 23

  • Classified as probably not a substantial claim.

    Findingown data

    The expert panel reached consensus that in addition to the DSM-5 diagnosis, a narrative account must be given that includes aetiology and pathogenesis.

    “In addition to the diagnosis according to the DSM-5, a narrative account must be given that includes aetiology and pathogenesis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The open definition in round 1 inspired two new criteria in round 2.

    “The open definition in round 1 inspired two new criteria in round 2.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Two diagnostic criteria that did not reach consensus were included in round 2 after rephrasing guided by the comments.

    “Two diagnostic criteria that did not reach consensus were included in round 2 after rephrasing guided by the comments (Tables 3 and 4).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The expert panel reached consensus that if there are indications that entering into a repeated psychotherapeutic trajectory is meaningful, this must be offered before IPS can be established.

    “If there are indications that entering into a repeated psychotherapeutic trajectory is meaningful, this must be offered before irremediable psychiatric suffering can be established. For example: because conditions were sub-optimal in previous therapy.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Various participants added that extensive treatment must have been tried and failed.

    “Various participants added that extensive treatment must have been tried and failed.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Several participants emphasized the importance of finishing the treatment protocol or trying all evidence-based treatments without relief of suffering.

    “Several emphasized the importance of ‘finishing the treatment-protocol’ or ‘trying all evidence-based treatments’ without relief of suffering.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most participants' definitions specified that a psychiatric disorder should cause suffering which is persistent, long lasting, chronic or constant.

    “Most participants’ definitions specified that a psychiatric disorder should cause suffering which is persistent, long lasting, chronic or constant.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    The expert panel reached consensus that if side effects allowed, the indicated drug treatments should have been adequately performed without leading to a significant reduction in suffering.

    “If side effects allowed, the indicated drug treatments should have been adequately performed without leading to a significant reduction in suffering.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The second round contained nine criteria.

    “The second round contained nine criteria (Table 4).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    The expert panel reached consensus that a psychiatric diagnosis, as described in DSM-5, should be established according to applicable guidelines.

    “A psychiatric diagnosis, as described in the DSM-5, should be established according to applicable guidelines.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    After two Delphi rounds, consensus was reached for 13 criteria, subdivided into five diagnostic and eight treatment-related criteria.

    “After two Delphi rounds, consensus was reached for 13 criteria, which can be subdivided into five diagnostic and eight treatment-related criteria (Table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In round 1, eight of 20 criteria reached consensus: three diagnostic criteria (A1, A3, B) and five treatment criteria (D, E, F, H, I); none of the treatment refusal criteria reached consensus.

    “Eight of 20 criteria reached consensus, three of which were diagnostic criteria (Table 2: A1, A3 and B), five were treatment criteria (Table 2: D, E, F, H & I), none of the treatment refusal criteria reached consensus.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Three other treatment criteria did not reach consensus and were adapted based on participants' comments and repeated in round 2.

    “Three other criteria did not reach consensus and were adapted based on participants’ comments and repeated in round 2 (Tables 3 and 4).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    The expert panel reached consensus that if necessary, substantial efforts should have been made to improve the patient's social situation without leading to a significant reduction in suffering.

    “If necessary, substantial efforts should have been made to improve the patient's social situation without leading to a significant reduction in suffering.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Findingnone given

    Others explicated that only reasonable treatment options can be demanded from the patient.

    “Others explicated that only reasonable treatment options can be demanded from the patient.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    The expert panel reached consensus that in addition to the DSM-5 diagnosis, it should be standard practice to verify whether there are contextual or systemic factors that cause or maintain the psychiatric complaints.

    “In addition to the diagnosis according to the DSM-5, it should be standard practice to verify whether there are contextual or systemic factors that cause or maintain the psychiatric complaints.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The expert panel reached consensus that if side effects allowed and if indicated, ECT should have been attempted for a sufficient length of time without leading to a significant reduction in suffering.

    “If side effects allowed and if indicated, electroconvulsive therapy (ECT) should have been attempted for a sufficient length of time without leading to a significant reduction in suffering.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Findingnone given

    If necessary, substantial efforts should be made to improve the patient's social situation.

    “Also, if necessary, substantial efforts should be made to improve the patient's social situation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The participants consider social interventions, including recovery-oriented approaches, important in the context of MAID.

    “The participants consider social interventions, including recovery-oriented approaches, important in the context of MAID.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Regarding the biological treatments, there is consensus that medication and ECT should have been tried, but not psychosurgery.

    “Regarding the biological treatments, there is consensus that medication and ECT should have been tried, but not psychosurgery.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants considered a DSM classification necessary when determining IPS, but even more, participants considered the presence of a narrative description and attention to psychosocial factors important.

    “Participants considered a DSM classification necessary when determining IPS, but even more, participants considered the presence of a narrative description and attention to psychosocial factors important.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    The Delphi panel reached consensus that structured psycho-diagnostic testing, including personality testing when relevant, should be performed, unless the psychiatrist provides clear reasons why it is not necessary.

    “Structured psycho-diagnostic testing, including personality testing when relevant, should be performed, unless the psychiatrist provides clear reasons why it is not necessary.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Based on the comments, two main reasons for dissensus emerge: participants find psychosurgery too experimental, too invasive, or both.

    “Based on the comments, two main reasons for dissensus emerge: participants find psychosurgery too experimental, too invasive, or both.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Ethical approval for the study was obtained from the Medical Ethical Examination Board of Amsterdam UMC/VUmc under registration number D326.

    “Ethical approval for this study was obtained from the Medical Ethical Examination Board of Amsterdam UMC/VUmc under registration number D326.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The round 1 survey was validated in a pilot phase with three senior psychiatry residents using the 'think aloud' approach.

    “The survey was validated in a pilot phase, during which three senior psychiatry residents from the Netherlands and Belgium filled out the survey in the presence of the corresponding author using the ‘think aloud’ approach. 9”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Priede C Farrall S. Comparing results from different styles of cognitive interviewing: ‘verbal probing’ vs. ‘thinking aloud’. Int J Soc Res Methodol. 2011; 14: 271- 287. 10.1080/13645579.2010.523187 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Most jurisdictions that permit MAID for PPD demand that the patient is competent and has a medical condition causing irremediable and unbearable suffering.

    “For this request to be granted, most of these jurisdictions demand that the patient is competent in her request and has a medical condition that causes irremediable and unbearable suffering.1,2”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] Kim SYH de Vries R Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016; 73(4): 362- 368. doi: 10.1001/jamapsychiatry.2015.2887 26864709 PMC5530592 source

      Not checked in the free run.

    • cites [2] Shaffer CS Cook AN Connolly DA. A conceptual framework for thinking about physician-assisted death for persons with a mental disorder. Psychol Public Policy Law. 2016; 22: 141- 157. 10.1037/law0000082 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The round 2 survey was piloted again on one senior psychiatric resident using the 'think aloud' approach.

    “The round 2 survey was piloted again on one of the senior psychiatric residents using the ‘think aloud’ approach.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Informed consent was obtained from all participants.

    “Informed consent was obtained from all participants, and everyone gave permission to be acknowledged for their efforts in the final publication, adding to the transparency of the study.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Participants were required to have at least five years of clinical experience as a psychiatrist and experience with assessing PPD requesting MAID.

    “In order to be included in the study (1) participants had to have at least five years of clinical experience as a psychiatrist and (2) they had to have experience with assessing PPD requesting MAID.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    53 psychiatrists completed round 1 (79% of 67 invited) and 47 completed round 2 (89% of round 1 respondents).

    “Sixty-seven psychiatrists, meeting the inclusion criteria, responded to an invitation to participate and were sent the survey; 53 psychiatrists completed the first round (79%), of these 47 completed round 2 (89% of those responding to round 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    Response stability was indicated by repetitive arguments, similar arguments to round 1, and no substantial new viewpoints, so no third round was performed.

    “Using the same standards as round 1 it was concluded that the wording was sufficiently clear for all criteria, arguments for agreeing or disagreeing were similar to round 1 and became repetitive, and no substantial new viewpoints were introduced by participants, indicating response stability. 12 Therefore, the outcomes of round 2 criteria were accepted and no third round was performed.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] von der Gracht HA. Consensus measurement in Delphi studies. Review and implications for future quality assurance. Technol Forecast Soc Change. 2012; 79: 1525- 1536. 10.1016/j.techfore.2012.04.013 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A Dutch euthanasia expertise centre recently stated that more clarity on psychiatric irremediability is a priority.

    “A Dutch euthanasia expertise centre recently stated that more clarity on psychiatric irremediability is a priority. 5”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Kammeraat M Kölling P. Psychiatrc Patients at the Expertise Centre Euthanasia [Dutch].

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Participants were purposely selected to include psychiatrists known as proponents, opponents, or holding a moderate stance on MAID for PPD.

    “Diverse perspectives were aimed for by purposely inviting psychiatrists who are known proponents, opponents, or hold a moderate stance on MAID for PPD.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The CREDES guidelines were followed.

    “Also, the ‘Conducting and REporting of DElphi Studies’ (CREDES) guidelines were followed. 8”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Jünger S Payne SA Brine J, et al. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: recommendations based on a methodological systematic review. Palliat Med. 2017; 31: 684- 706. DOI: 10.1177/0269216317690685 28190381 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A Canadian expert advisory group has called for more research on the irremediability of psychiatric suffering.

    “A Canadian expert advisory group has also called for more research on the irremediability of psychiatric suffering. 6”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Gaind KS. Canada at a Crossroads: Recommendations on Medical Assistance in Dying and Persons With a Mental Disorder. 2020. doi: 10.13140/RG.2.2.36236.87687 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study protocol was preregistered at the Open Science Framework under project code qx5hy.

    “The study protocol was preregistered at the Open Science Framework under project code: qx5hy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    A privacy impact assessment was performed, assuring compliance with European privacy laws.

    “Furthermore, a privacy impact assessment was performed, assuring compliance with European privacy laws.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    A recent qualitative study on IPS among Dutch psychiatrists with experience in establishing IPS in the context of MAID concluded that consensus criteria are needed to guide current clinical decision-making.

    “A recent qualitative study on irremediable psychiatric suffering (IPS) among Dutch psychiatrists with experience in establishing IPS in the context of MAID concluded that consensus criteria are needed to guide current clinical decision-making. 7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] van Veen SMP Ruissen AM Beekman ATF, et al. Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study. CMAJ. 2022; 194(3). PMC8985907 35273025

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The participants had relevant experience with MAID for PPD: 91% had received a MAID request, 81% had performed an independent consultation, and 23% had performed MAID.

    “Of these participants, 75% worked in the Netherlands, 21% in Belgium and 4% in both countries; 91% had received a MAID request from one or more of their own patients, 81% had performed an independent consultation and 23% had actually performed MAID due to psychiatric suffering.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    This can be seen as an argument for a diligent assessment of IPS, which requires experience and expertise of participants, as well as joint deliberation, in order to apply the criterion to an individual case.

    “This can be seen as an argument for a diligent assessment of IPS, which requires experience and expertise of participants, as well as joint deliberation, in order to apply the criterion to an individual case.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The criterion also implies that when there is no need for improving social support or if proper support does not reduce suffering, IPS may still be established and MAID may still be justified.

    “But the criterion also implies that when there is no need for improving social support or if proper support does not reduce suffering, IPS may still be established and MAID may still be justified.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Because we had to change the criteria in between rounds we were not able to calculate response-stability for any of our questions, which could have been a valuable addition to the current qualitative analysis of response stability.

    “Also, because we had to change the criteria in between rounds we were not able to calculate response-stability for any of our questions, which could have been a valuable addition to the current qualitative analysis of response stability.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] von der Gracht HA. Consensus measurement in Delphi studies. Review and implications for future quality assurance. Technol Forecast Soc Change. 2012; 79: 1525- 1536. 10.1016/j.techfore.2012.04.013 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    In the context of MAID, the biopsychosocial model can serve as a helpful framework to assess individual treatment criteria.

    “In the context of MAID, it can serve as a helpful framework to assess individual treatment criteria.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    As none of the specific treatment refusal criteria reached consensus, no conclusions can be drawn regarding specific psychiatric treatments the patient should undergo before IPS can be established in the context of MAID.

    “However, as none of the specific treatment refusal criteria reached consensus, no conclusions can be drawn regarding specific psychiatric treatments the patient should undergo before IPS can be established in the context of MAID.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Continuing to treat patients if no effect is to be expected could be harmful, especially when coercion and burdensome procedures are used.

    “This is problematic, because continuing to treat patients if no effect is to be expected could be harmful, especially when coercion and burdensome procedures are used.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    This is not only true for the criterion on treatment refusal but also holds for the criteria in general.

    “This is not only true for the criterion on treatment refusal but also holds for the criteria in general.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    This may be read as support for the often used argument against MAID stating that when a patient with a psychiatric disorder wants to die, we should improve their situation, not offer MAID.

    “This may be read as support for the often used argument against MAID stating that when a patient with a psychiatric disorder wants to die, we should improve their situation, not offer MAID.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Vulnerable persons standard. 2016. [ accessed 2021 March 24). http://www.vps-npv.ca/.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    It may be justified to only demand additional diagnostic procedures, such as neuropsychological or personality testing, when there is a reasonable chance that this will lead to new treatment options with a high probability of reducing suffering.

    “It may be justified to only demand additional diagnostic procedures, such as neuropsychological or personality testing, when there is a reasonable chance that this will lead to new treatment options with a high probability of reducing suffering.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    A strength of this study is that we were able to access a substantial group of psychiatrists with ample experience in assessing MAID requests, and representing different views on psychiatric MAID.

    “A strength of this study is that we were able to access a substantial group of psychiatrists with ample experience in assessing MAID requests, and representing different views on psychiatric MAID.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A limitation of a consensus-building Delphi survey is that the structure of the questionnaire is determined by the researchers, and participants' comments are interpreted by the project group, limiting the influence of the participants.

    “A limitation of a consensus-building Delphi survey is that the structure of the questionnaire is determined by the researchers, and participants’ comments are interpreted by the project group, limiting the influence of the participants.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisereasoning

    This is in line with the biopsychosocial model of psychiatric suffering and treatment, which was introduced by George Engel in 1977, and is still highly influential in contemporary psychiatry.

    “This is in line with the biopsychosocial model of psychiatric suffering and treatment, which was introduced by George Engel in 1977, and is still highly influential in contemporary psychiatry.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977; 196: 129- 136. doi: 10.1126/science.847460 847460 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The comments showed that all criteria were well understood and therefore both the dissensus and the consensus that was found were regarded as valid and no new round was started.

    “The comments showed that all criteria were well understood and therefore both the dissensus and the consensus that was found were regarded as valid and no new round was started.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    This criterion should be used with caution, as it is difficult to reliably evaluate the quality of earlier psychotherapy, and knowledge about the efficacy of repeated psychotherapy for therapy-resistant psychiatric complaints is lacking.

    “This criterion should be used with caution, as it is difficult to reliably evaluate the quality of earlier psychotherapy, and knowledge about the efficacy of repeated psychotherapy for therapy-resistant psychiatric complaints is lacking.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [7] van Veen SMP Ruissen AM Beekman ATF, et al. Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study. CMAJ. 2022; 194(3). PMC8985907 35273025

      Not checked in the free run.

    • cites [23] van Bronswijk S Moopen N Beijers L Ruhe HG Peeters F. Effectiveness of psychotherapy for treatment-resistant depression: a meta-analysis and meta-regression. Psychol Med. 2019; 49: 366- 379. doi: 10.1017/S003329171800199X 30139408 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Although the criteria are specifically established for patients requesting MAID, they can serve as inspiration for examining psychiatric irremediability in general.

    “Although the criteria are specifically established for patients requesting MAID, they can serve as inspiration for examining psychiatric irremediability in general.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Implementation of this criterion as a due diligence requirement might provide clarity for patients and regulators about the high threshold of irremediability in the context of MAID for PPD.

    “Implementation of this criterion as a due diligence requirement might provide clarity for patients and regulators about the high threshold of irremediability in the context of MAID for PPD.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    We did not include relatively new treatments which were less widely used in the Netherlands and Belgium at the time of the study, such as transcranial magnetic stimulation or psychedelic treatments, as potential criteria.

    “Finally, we did not include relatively new treatments which were less widely used in the Netherlands and Belgium at the time of the study, such as transcranial magnetic stimulation or psychedelic treatments, as potential criteria.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    This allows for treatment refusal, which is an important theme in the debate about IPS in the context of MAID.

    “This allows for treatment refusal, which is an important theme in the debate about IPS in the context of MAID.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    This shows that effectiveness and proportionality should be taken into account when deciding on treatment criteria.

    “This shows that effectiveness and proportionality should be taken into account when deciding on treatment criteria.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The current criterion, that only states that there should be limits, leaves room for interpretive differences between psychiatrists, patients and other stakeholders.

    “The current criterion, that only states that there should be limits, leaves room for interpretive differences between psychiatrists, patients and other stakeholders.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    This is at odds with the suggestion that working towards acceptance of suffering can be seen as a subsidiary option to psychiatric MAID.

    “This is at odds with the suggestion that working towards acceptance of suffering can be seen as a subsidiary option to psychiatric MAID.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] van Veen SMP Ruissen AM Widdershoven GAM. Irremediable psychiatric suffering in the context of physician assisted death: a scoping review of arguments in the literature. Can J Psychiatry. 2020; 65: 593- 603. doi: 10.1177/0706743720923072 32427501 PMC7457463 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    By reliably establishing that suffering is irremediable, we may recognize further curative treatment as futile and shift to palliative approaches.

    “By reliably establishing that suffering is irremediable, we may recognize further curative treatment as futile and shift to palliative approaches.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [25] Levitt S Buchman D. Applying futility in psychiatry: a concept whose time has come. J Med Ethics. 2020: 47: e60. doi: 10.1136/medethics-2020-106654 33443107 source

      Not checked in the free run.

    • cites [26] Trachsel M Irwin SA Biller-andorno N, et al. Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry. 2016; 16: 1- 6. doi: 10.1186/s12888-016-0970-y 27450328 PMC4957930 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    It may also be relevant for distinguishing MAID requests from impulsive suicidality.

    “It may also be relevant for distinguishing MAID requests from impulsive suicidality.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Pronk R Willems DL van de Vathorst S. Do doctors differentiate between suicide and physician-assisted death? A qualitative study into the views of psychiatrists and general practitioners. Cult Med Psychiatry. 2021; 45: 265- 281. doi: 10.1007/s11013-020-09686-2 PMC8110501 32833142 source

      Not checked in the free run.

62 of 62

  • The paper relies on this without support.

    Patients with a psychiatric disorder are eligible to request medical assistance in dying in a small but growing number of jurisdictions, including the Netherlands and Belgium.

    “Patients with a psychiatric disorder are eligible to request medical assistance in dying (MAID) in a small but growing number of jurisdictions, including the Netherlands and Belgium.”

  • The paper relies on this without support.

    MAID has been permitted in psychiatric practice in the Netherlands and Belgium for over 20 years.

    “focusing on the Netherlands and Belgium where MAID has been permitted in psychiatric practice for over 20 years.”

  • The paper relies on this without support.

    No widely accepted benchmark exists within the research community of what constitutes an adequate level of consensus.

    “Moreover, no widely accepted benchmark exists within the research community of what constitutes an adequate level of consensus.”

  • The paper relies on this without support.

    Psychiatry rarely discusses when to stop treatment.

    “Psychiatry is beginning to understand how to rationally deploy sequential treatment modalities, but when to stop treatment is rarely discussed.”

  • The paper relies on this without support.

    In the Netherlands, the law requires that patient and physician make a shared decision about treatment refusal.

    “In the Netherlands, the law requires that patient and physician make a shared decision about treatment refusal.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The same group agreed that complaints should be present for at least a few years, if only to give all these treatments a chance, and that there should be limits to the number of treatments and diagnostic procedures a patient should undergo before IPS can be established.

    “They also agreed that the complaints should be present for at least a few years, if only to give all these treatments a chance. Finally, this group agreed that there should also be limits to the number of treatments and diagnostic procedures a patient should undergo before IPS can be established.”

    From Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands (2022) · cites this paper as [23]

  • In a study, 53 experienced Dutch and Belgian psychiatrists agreed that a proper psychiatric diagnosis, taking into account contextual factors, is necessary for IPS; all indicated biological and psychological treatments should have been tried, at least one recovery-oriented treatment should have been tried, and if necessary substantial efforts should have been made to improve the patient's social状況

    “In another study, 53 experienced Dutch and Belgian psychiatrists were asked to reflect on potential criteria for IPS in the context of PAD (23). They agreed that a proper psychiatric diagnosis, that takes into account contextual factors, is necessary. All indicated biological and psychological treatments should have been tried, at least one recovery-oriented treatment should have been tried and if”

    From Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands (2022) · cites this paper as [23]

  • Canada has approved legislation to take effect in 2023 allowing individuals with "irremediable psychiatric suffering" to seek medical aid in dying, regardless of an otherwise terminal medical condition.

    “Indeed, Canada has approved legislation to take effect in 2023 that will allow individuals with “irremediable psychiatric suffering” to seek MAID, regardless of an otherwise terminal medical condition [16].”

    From Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward (2022) · cites this paper as [16]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Round 1 non-religious percentage uses the wrong denominator

    Minor

    Table 1 reports 42 non-religious respondents as 89% of the 53 Round 1 respondents, but 42 of 53 is about 79%.

    Reported 89 · recomputed 79.245283

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. van Veen SMP, 2018, J Ethics Ment Heal, 10
  2. van Veen SMP, 2022, CMAJ, 194
  3. 2015, Regional Euthanasia Review Committess RTE: Code of Practice, 1, 26

Cited by

Sorted by citations

Related

Authors
van Veen, S. M. P., Evans, N., Ruissen, A. M., Vandenberghe, J., Beekman, A. T. F., & Widdershoven, G. A. M.
Affiliations
  • Department of Psychiatry, Amsterdam University Medical Center, the Netherlands
  • Amsterdam University Medical Centers (NL)
  • KU Leuven (BE)
  • GGZ inGeest (NL)
ORCID
Venue
The Canadian Journal of Psychiatry
Publisher
SAGE Publications
Published
2022-03-21
Volume
67
Issue
10
Pages
758-767
ISSN
  • 0706-7437 (ISSN-L)
  • 1497-0015
DOI
10.1177/07067437221087052
PMC
PMC9510999
OpenAlex
W4221131948
Semantic Scholar
1af964daf24512c03a53e34be712068467bb9c73
Cited by
21
References
22
Citations by year
2026: 3 · 2025: 3 · 2024: 5 · 2023: 5 · 2022: 5
FWCI
4.19
Type
journal article
Language
en
Open access
Licence
Locations
  • The Canadian Journal of Psychiatry (publishedVersion, cc-by)
  • medRxiv (acceptedVersion)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion, other-oa)
  • Lirias (submittedVersion, cc-by)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
Keywords
medical assistance in dying, mental illness, eligibility criteria, second opinion, biopsychosocial treatment, treatment refusal, expert consensus, clinical decision-making
MeSH terms
Mental Disorders, Canada, Female, Humans, Medical Assistance, Psychiatry, Suicide, Assisted

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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