title: Quality of ethical guidelines and ethical content in clinical guidelines: the example of end-of-life decision-making.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centre for Ethics and Law in the Life Sciences (CELLS), Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Carl-Neuberg Strasse 1, Hannover, Germany. strech.daniel@mh-hannover.de
authors.forename: Daniel
authors.initials: D
authors.lastname: Strech
authors.forename: Jan
authors.initials: J
authors.lastname: Schildmann
mesh_terms: D016223:Advance Directives / Q000941:ethics; D003657:Decision Making / Q000941:ethics*; D006801:Humans; D017410:Practice Guidelines as Topic; D013727:Terminal Care / Q000941:ethics*