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Quality of ethical guidelines and ethical content in clinical guidelines: the example of end-of-life decision-making
  1. Daniel Strech1,
  2. Jan Schildmann2
  1. 1CELLS – Centre for Ethics and Law in the Life Sciences, Institute for History, Ethics, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
  2. 2Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum
  1. Correspondence to Professor Daniel Strech, CELLS – Centre for Ethics and Law in the Life Sciences, Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Carl-Neuberg Strasse 1, 30625 Hannover, Germany; strech.daniel{at}


Background While there are many guidelines on how to make ethical decisions at the end of life, there is little evidence regarding the quality of this sort of ethical guidelines.

Objectives First, this study aims to demonstrate the conceptual transferability of the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument for the quality assessment of ethical guidelines. Second, it aims to illustrate the status quo of the quality of guidelines on end-of-life decision-making by using the AGREE instrument in a first practice test.

Method The transferability of the AGREE instrument on the quality assessment of ethical guidelines is demonstrated by conceptual analysis. Guidelines on end-of-life decisions in medicine are identified through a systematic search in MEDLINE (from June 1999 to June 2009). The quality of all included guidelines was assessed with a slightly modified AGREE instrument.

Results Of 103 guidelines identified, 34 were included as relevant. The majority of the guidelines analysed in this study were assessed as qualitatively insufficient in five out of six AGREE quality domains. A few guidelines demonstrated, however, that a high level of quality in accordance with the AGREE requirements is possible.

Conclusion This review concludes that the quality of many ethical guidelines should and can be improved in all quality domains specified by the AGREE instrument. Furthermore, conceptual analysis indicates that a slightly modified AGREE instrument is transferable to the comprehensive evaluation of the quality of ethical guidelines. Nevertheless, future research is needed to improve the assessment of the presentation of the guidelines' normative basis.

  • AGREE instrument
  • care of the dying patient
  • decision making
  • end of life
  • ethical guidelines
  • policies
  • position statements (of organisations/groups)
  • prolongation of life and euthanasia
  • quality of guidelines

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  • Funding Dr. Strech's work has been partly funded by the German Research Foundation (DFG) through the research project EthicsGuide (STR 1070/2-1). Dr. Schildmann's work as head of the NRW Junior Research Group: ‘Medical Ethics at the End of Life: Norm and Empirism’ is funded by the Ministry for Innovation, Science, and Research of the German state of North Rhine-Westphalia.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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