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Table 3 Impact of the euthanasia procedure on Adults with Psychiatric Conditions’ state of mind, including death ideation, in the context of the euthanasia request being neglected (N), rejected (R), under review/being assessed (A), granted (G) or put on hold (P)

From: The impact of the euthanasia assessment procedure: a qualitative interview study among adults with psychiatric conditions

Favourable outcome Unfavourable outcome
Feeling heard Feeling recognised/heard/understood
- Relief of being enrolled for future euthanasia assessment (A, P)
- Being recognised/heard as regards the burden of suffering/problems in life (A, G)
- Being seen as a whole (not only sick) person (G, P)
Immediate impact at having request granted (G)
- “euphoria”, “intense happiness”, “contentment”
Not feeling recognised/heard/understood
- Being fended off (N, R)
- Not being taken seriously/heard (N)
- Being misunderstood as regards the burden of (invisible) suffering/problems in life (N, R)
Fear for adverse events Less fearful of unwanted events (A, G)
- No (more) fear for involuntary admissions to a psychiatric ward
- Less burdened with ‘self-destructive ideation and behaviors’
- Increased ability/willingness to suppress suicidality
Relief for loved ones when no formal advice on the request has been obtained
- not to have burdened loved ones (N, R, A)
- not to have burdened one self with further discussions on the subject (N, R)
More fears/thoughts regarding death and dying
- Fearful of new (failed) suicide attempts (N, R, A)
- Ambiguity about dying (fear of dying, afterlife) (A)
- Time-consuming ruminations regarding *(unregulated) suicide (N, R, A) vs *euthanasia (A)
- Time-consuming practical preparations for euthanasia (A,G)
Distress about consequences of having request granted
- stigma/labelling if APC does meet the legal criteria (A) eg. jeopardise potential opportunities in life
- ambiguity about dying (fear of dying, afterlife) (A)
- Uncertainty < probability of the window of opportunity narrowing/closing: (A,G)
*professional backing out * legislation change *validity period of obtained positive advices
(eg. physician’s retirement)
Creating Perspective, empathy Better understanding of/empathy toward others’ perspectives
*Towards physicians
- Understanding/empathy towards rejection *from treating psychiatrist (R, A)
*from performing physician (A, G, P)
- Understanding/empathy towards physicians as regards the difficulties faced and the necessity of building sufficient reflection time (A, G, P)
- Understanding/empathy towards physicians entrusted with euthanasia assessment (A, G, P)
*Towards the social inner circle
- Understanding/empathy: regained ability to take important others’ perspective into account (A)
- Regained ability to deal with different perspectives and reactions (A, G, P)
Perceived control Ability to plan a good death
- eg. planning and exchanging goodbyes, memorial celebration (G)
- Reframing the death wish (A, G, P)
eg. ‘euthanasia’ as potential safety net >  < acute death request
Feelings of powerlessness, having no control (A, G)
- Burden of pleading tribunal hearings’ (A, G)
(pleas instead of requests for euthanasia)
- Perception of being given the runaround (A, G)
- Experiences of broken promises/physicians getting cold feet (A)
- Distress about the uncertainty of the outcome (A)
*the probability of broken promises, tightening of the law (A)
(Di)stress when the outcome turns out negative
- despair, hopelessness (N, R)
- indignation (R)
- Feeling left in the dark/to their fate to find new physicians (N)
Burden of the quest in finding physicians open to euthanasia (N, R)
Fairness   Feelings of injustice, unfairness (A, G, P)
- Unprofessional behaviour of physicians involved
*violation of medical secrecy/confidentiality
* poor communication skills (induced false hope, lack/little transparent communication between physicians involved)
- Inequality of the euthanasia procedure and outcomes associated with
*patient characteristics ie. the highly intelligent, verbally skilled APC and those who have important other’s approval are in the advantage
* the absence of one single standard protocol approach ie. law versus a variety of guidelines
Emotional drain   Procedure itself is emotionally draining
- Reluctance/burden of (repeated) self-disclosures (A, G, P)
- Assessment procedure is hard/too time-consuming/over-burdening (while being exhausted) (A, G)
- Being the victim of dissensions between EOL centres/played out by the dissensions between strong opponents and proponents (A)
Distress about loved ones Relief not (yet) to burden loved ones (N, R) Distress about consequences of the euthanasia procedure on loved ones
- Burdening loved ones (A,G)
- Concerns about bottled up emotions inside loved ones (N, R, A, G, P)