In Poland, it’s best to die in a hospital or hospice. Death at home is a problem for the family and the doctor

It is assumed that around 150 people die at home in Poland. people per year. However, in the light of the regulations still in force at the turn of the 50s and 60s, if you die, you must die in a hospital or in a hospice. Unfortunately, it is impossible to plan death from natural causes, so we will continue to leave this world at home, which may become the beginning of problems not only for our relatives, but also family doctors and … officials.

1.  In Poland, deaths are established on the basis of the provisions of the Act of 1959 and the Regulation of the Minister of Health of 1961. 
2. The institution of the coroner, or the person responsible for declaring deaths, was introduced in 2002. It is a forensic doctor
3. In the Krakow poviat, where the doctor Aleksander Biesiada consults, the County Office does not employ a coroner 
4. Dr. Biesiada brought a lawsuit against the starosty because he hopes that the staroste will appoint a person who will take care of declaring home deaths, and family doctors will not have to choose whether to go to death or treat patients
5. More information can be found on the Onet homepage

The act of 31 January 1959 on cemeteries and the burying of the deceased was not amended despite the intervention of the Commissioner for Human Rights. Much has been said and written about the need to change archaic regulations during the coronavirus pandemic, but in the fall of last year, the matter died down.

The applicable law states that the poviat staroste and the town mayor with poviat rights are responsible for declaring deaths in a situation where a doctor cannot do it.. This is a job for a coroner they can appoint. However, officials must show good will, as signing a contract for its services is not the county’s own task and should be financed from the state budget. So there are poviats where coroners operate, but there are also poviats where they do not exist.

And why do we need a coroner?

A family medicine specialist, doctor Aleksander Biesiada, consults a small clinic in the Krakow poviat. Last September he was in his office from the morning, it was going to be a very busy day. Before 9, the registrar answered a phone call asking for a death certificate to be issued. The family found a deceased relative in the house, called an ambulance, but ambulances do not go to the deceased.

– I sent the information through registration so that they contact the poviat starosty and arrange the arrival of the person indicated by the staroste, i.e. the coroner, who will confirm the death and issue a death certificate – says Dr. Biesiada. – I had a full patient clinic and I worked alone. In addition, home visits were planned, it was not possible to go to the deceased. I am not allowed to leave my workplace, I am responsible for patients in the clinic and during home visits. During working hours, I have to be on site and heal.

The Act of 1959 on the declaration of death and the issue of a death certificate states in Art. 11.1: Death and its cause should be established by the physician treating the patient in the most recent illness.

In the event of failure to complete the provision of paragraph. 1, the declaration of the death and its cause should be made by visual inspection by a doctor or, failing that, by another person appointed for this activity by the competent staroste, and the costs of these inspections and the issued certificate may not be charged to the family of the deceased.

On the other hand, in the regulation of the Ministry of Health and Social Sciences of 1961 on the declaration of death and its causes, we read: The issuing of the death certificate is the responsibility of the physician who last provided the patient with medical services within 30 days before the date of death.

– I was neither a doctor treating the deceased in the last disease, nor did I provide benefits to him in the last 30 days of his life – says Dr. Biesiada.

After an hour, the family of the deceased calls the clinic again, informing that their request was ridiculed by the employees of the County Office. Officials said the death was to be decided by a health care physician.

– I work in Radziszów, in the only health care center in this area – adds the doctor. – The deceased submitted a declaration to the POZ, but there was no continuity of treatment, as provided for in the act.

Two hours pass, the deceased’s family comes to the clinic.

– They told me that they contacted the starosty again and heard that the coroner was not hired, so there is no possibility for anyone to come to confirm the death, and this obligation rests with the GP, says Dr. Biesiada.

Now a doctor is calling to the district office. He is talking to the sub-inspector, who seems to be more conciliatory. Since the starost did not appoint a coroner and the regulations are unclear, the clerk asks him to go and find the death.

– Finally, after a whole day of work, around 18.30 pm, I went, because in my opinion it is unethical to leave people without help – recalls the doctor. Anyway, they understood that I couldn’t drop my patients and go to them immediately. The office probably counted on the fact that, under the pressure of my family, I would bow down and help me out with the goodness of my heart. And it is clear that I will want to help. I am a doctor who treats entire families. The relatives of the deceased trust me. It is on this trust that I base my relationship with them. We are in the XNUMXst century, we live in the center of Europe, I consider the actions of the eldership as inhumane, disregarding the epidemiological threat that the deceased could have posed.

After a few days, Dr. Biesiada consulted the District Medical Chamber in Krakow, asking for support. He sent the staroste a bill for his work, but as he says, the most important thing was that the office should appoint a coroner or consulted the doctors working in its area on this matter.

– First, I asked the starosty to deal with this matter myself, and then the medical chamber requested it, sending a letter to the starost asking for the appointment of a person indicated in the act – the doctor recalls.

– The staroste wrote back that he did not see such a possibility. He referred to the provision that it was the duty of a doctor treating in his last illness. Only in this case there was no such doctor. He wrote that the legislator, apart from amendments to the act, did not make appropriate adjustments to the executive law on the determination of death and its causes, which resulted in a legal loophole regarding the principles of summoning a doctor or other authorized persons to perform the activities of declaring death and the principles of covering expenses. He also referred to the college of the Regional Audit Chamber, from which I conclude that the main problem here is money. The magazine ended with a request that doctors, despite being underfinanced, should act for the welfare of the deceased’s families, he explains.

The coroner only when called by the police

– Imagine a situation where the patient died at home at 5 am, so the family at 8 show up at the clinic, says Maciej Pawłowski, MD, PhD, who works at POZ in Łódź. – And the doctor has patients registered on that day until 15. If a declaration of death does not meet the terms of the Act, a problem arises. I am suing the Łódź City Hall because of such a death. After a fight with the coroner, I went to find the death myself, because the law says that it must be done within 12 hours. The family wants it as soon as possible, which is understandable, so you need to hire a coroner to be on call and confirm the deaths. Meanwhile, savings are being sought.

To dr. Pawłowski after At 8 a.m. the family of the deceased reported immediately to declare the death, which, according to them, had occurred two hours earlier. After checking the documentation, it turned out that the last service for this person took place more than 30 days ago, and his disease was not treated in a primary health care facility. For confirming the death, the doctor issued a bill for the amount of PLN 150 to the city hall. The office refused to pay.

Act of 1959, § 3. Inability to issue a death card by an obliged entity: If there is no doctor obliged to issue a death card in accordance with § 2, par. 1 or such a doctor resides at a distance of more than 4 km from the place where the body is located, or due to illness or other justified reasons, he cannot inspect the body within 12 hours from the time of the call, the death certificate shall be issued by:

1. a doctor who declared the death when summoned to an accident or sudden illness, 
2. a doctor or a senior medical assistant or a medical assistant employed in a clinic or health center or its field facility (rural, medical medical center) and providing health care over the area where the body is located. 

– Officials say that the POZ doctor takes care of the area and hence the obligation to declare death, but this is nonsense, because there has been no zoning for at least 18 years, since the law on health care facilities has been in force – adds Dr. Pawłowski. – District doctors were in the times of the Polish People’s Republic, now the patient submits a declaration to a doctor who can see, for example, in another city. Similarly, there is no zoning anymore when providing hospital or outpatient services.

According to family doctors, under the law in force, they are not always obliged to certify death. For example, it says that they do not have to declare death if they live more than 4 km from the body.

– I live on the outskirts of the city and work in the city center – explains Dr. Pawłowski. – I have 7 km in a straight line to the clinic, and 8 km along the streets. That is, death in the vicinity of the clinic, by definition, is not for me, because I do not meet the criteria of the act. There is also the problem of the doctor treating the last disease, because there is no documentation flow. A death can be confirmed by any doctor, and I do not know if the patient I consulted yesterday later went to an ophthalmologist in Gdańsk or to a dermatologist in Rzeszów. Then they would be obliged to declare the death as they treated the patient in the last illness.

Another problem arises in the case of cancer patients, because primary health care does not cure them. If a patient dies at home in the course of cancer, the question arises whether the GP treated him in his last illness?

– If I prescribed this patient a prescription for an antiallergic drug, not related to cancer, 31 days before his death, I also do not meet the criteria of the act and I am not obliged to declare death – argues Dr. Pawłowski. – Although we know the patient well, he has been treated with us for years, the regulations are regulations, but we can do something for him and his family. On the other hand, when the patient has only made a declaration and has not been to us and no one knows who it is, and suddenly the family comes to ask for a declaration of death, the regulations decide. We did not treat him in the last disease.

Is a declaration of death by a family doctor a job?

It takes him well over an hour to confirm the death in the suburban area where Dr. Biesiada works.

– It takes about 30 minutes to travel back and forth, and 30 to 40 minutes on the spot, depending on whether I know the patient, whether I have any documentation or not – he says. – And if I have doubts whether the death was due to natural causes … Then we have to call the police, the police have to come, there is a prosecutor’s decision, and I am waiting on the spot all the time, even for several hours.

Again, the 1959 Act: § 9. Fee for issuing death certificates:

1. A doctor, senior medical assistant, medical assistant, nurse or midwife is entitled to a lump sum remuneration determined on the basis of § 7, section 2 of the Regulation of the Council of Ministers of December 12, 1958 on the salaries of doctors, dentists and other employees with higher education employed in social health care institutions (Journal of Laws No. 74, item 376) or § 18 sec. 2 point 3 of the Regulation of the Council of Ministers of December 12, 1958 on the salaries of certain health care workers (Journal of Laws No. 74, item 379). 
2. Persons mentioned in sec. 1 is also entitled to reimbursement of the actual travel costs, if the body is more than 1 km from the place of employment or residence of these people. 

– The starost indicated by the law should pay for the confirmation and issue of the death certificate. In practice, the family doctor does not receive any remuneration for this, emphasizes Dr. Biesiada. – He does it for ethical reasons after work.

Doctor Biesiada sent an invoice to the County Office. And because it had not been regulated, he took legal action.

“My main goal is to draw attention to the problem,” he emphasizes. – If the court upholds my arguments and decides that the staroste must pay, the starosty will no longer hide behind the Regional Audit Chamber. Since the funds are to be paid to me, you may as well appoint a person in the poviat to confirm the deaths. I hope that the staroste will appoint this person, establish procedures and take care of the deceased’s relatives. And family doctors will be saved from dilemmas: death trip or treatment of patients.

Doctors say that a lot of such cases happen. However, hardly anyone has enough self-denial to bring a case to court.

– County offices hope that the doctor will behave ethically – sums up Dr. Biesiada. – On the other hand, it is not fair to the families of the deceased and to family doctors who have to find their place in this system.

Doctor Aleksander Biesiada is a family medicine specialist, a GP in Radziszów and a home hospice doctor in Kraków. Also consider him as the author of the blog on palliative care: www.mistrzpolikarp.pl and co-author of a textbook on communication between doctors and patients

Maciej Pawłowski, MD, PhD is a specialist in paediatrics, specializing in family medicine. Completed a course in travel medicine entitling him to provide consultations in this field. He lives and works in Łódź.

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