In Poland, like in other parts of Europe, for centuries there have been hospices for the seriously ill and dying, run by Christian orders and fraternities. The contemporary vision of terminal care was first delivered by a nurse, Hanna Chrzanowska, the organizer of home nursing in Cracow. In 1931 she wrote: “A nurse should in a way double her efforts for a patient, trying to bring them relief, administering prescribed medications and performing procedures to the last minute. Her behaviour should be characterized by calm, earnestness and compassion for the family, whom she should support morally, without excessive sentimentality” (1). During the communist post war era these inspirations for the modern hospice movement in Poland were based on the experience of nurses’ concern for patients and their relatives: “The Polish hospice model is founded on the human, protective tradition of Polish medicine, nursing in particular. Hanna Chrzanowska captured the essence of the crisis of contemporary healthcare—the underdevelopment of the care system—before Dr Saunders, and she tried to remedy it. The Polish Hospice has to undertake the goal, ideals and style of nursing work delineated by her” (2).
Democracy in Poland and Eastern Europe arrived after a long fight with a communist regime attributed to the collaborative experience of solidarity between different groups of people and social sectors but also with the aptly named Solidarity Movement itself (Solidarność) described as the first free trade union in Poland since 1980’s. Both expressions of ‘solidarity’ were considered a significant shift away from the previous national mentality which has been named Homo Sovieticus. From a national psyche perspective, Homo Sovieticus appeared to lack any personality and dignity, being intellectually enslaved, incapable of independent thinking and acting, apathetic and passive, yet demonstrating aggression towards the weaker individuals, while keeping a servile stance towards those who were stronger (3). In contrast to this former national attitude the activities of medical volunteers have been developed in opposition to the Homo Sovieticus mentality in Poland—instead as an expression of human solidarity organized in cooperation with Solidarność—the Solidarity Trade Union in Poland. The Hospice Movement in Poland from 1981 onwards continued informal activities of a group of enthusiasts, inspired by Hanna Chrzanowska, supported by visits of Dr. Cicely Saunders, resulting in the creation of St. Lazarus Hospice in Cracow in 1981 (4). The public debate then considered the place of very ill people in society, as well as the issue of how to make our medicine more humane and assume the stance of “A Good Samaritan”, which had tremendous value of overcoming the Homo Sovieticus mentality in the then health care and social welfare systems in Poland (3). After the declaration of martial law and the abolition of Solidarity on 13 December 1981, the spirit of solidarity within the suffering of local communities found a new expression in the form of home care for dying people and their relatives, based on a volunteer movement, and organised together with Catholic parishes (5). This simple model of compassionate care, based on the accommodation available within the Church and the voluntary work of medical professionals, subsequently developed in other towns and cities all over Poland. With simple tools at the hands of the teams of home-care volunteers, this form of human solidarity fostered the expansion of the numbers of people involved in the system, and in turn led to the start of domestic care of people in the whole country. This team became the basis for more than 100 home care programs in Poland, emerging from the voluntary work of physicians, nurses, chaplains, and other volunteers (6).
The Catholic Church was, and still is, a very strong supporter of hospice programmes in Poland. In 1987 Pope John Paul II recognised the great amount of work done by hospice volunteers. His blessing was decisive for the further development of the Hospice Movement in Poland. Bishops and parish priests became more open to doctors, nurses and other people, asking their local church to start a hospice program (7). Informal training became available to doctors and nurses in Poland. Many hospice volunteers had the opportunity to go to London, to be trained at St. Christopher’s Hospice. A personal friendship between Dame Cicely Saunders and many Polish doctors and nurses, as well as the support of many charitable organisations, helped to develop most of the hospice programmes based on voluntary service (5). We were taking our first steps in learning what is volunteering after years of it being abused by the regime to disseminate propaganda, brainwash children and youth making it obligatory for voluntary actions in schools and local communities.
Integration of hospice and palliative care
It is worth noting that the pre-history of modern end-of-life care in Poland was connected to caring communities, which we can call compassionate. As mentioned in one book regarding volunteering in Europe: “For around 10 years there were only volunteers in hospices in Poland, nobody was paid for their activities: doctors, nurses, psychologists, social workers, chaplains. Everything ran on a voluntary basis, which I think is quite unusual in comparison to other programs in Europe. We had a lot of support from churches and also help from abroad. There was a lot of foreign help and assistance during that time - solidarity support and charitable transports with medication and equipment, which we used in our home care. We can say that many parishes and other organisations from Western Europe: Germany, Austria, France, Belgium, Holland and Scandinavia - were in way co-founders of our modern hospice movement, because most of the equipment and medication was donated by them for our teams.” (8). Along with the democratic changes since 1989 in Poland and the rest of Eastern Europe there came changes in end-of-life care. Gradually, palliative medicine—started to become a part of the national healthcare program. The first Palliative Medicine Department was created in the Medical University of Poznan, and it supplies scientific knowledge to the voluntary structures (9). In 1994 the first home care children’s hospice was established in Warsaw, setting an example for children’s hospices in Poland (10).
Following those democratic changes, Poland as well as Eastern Europe faced a completely new socio-economic situation. A drop in the number of volunteers offering their help to charitable organizations, including hospices, was noted. This was due to the fact that people started to seek jobs en masse in order to cope with growing problems posed by the new reality. Volunteers who engaged as hospice physicians and nurses were employed in palliative medicine centres which were slowly merging into an institutional framework of the health care system. The hospice movement was slowly losing its exceptional character of professionals working together with volunteers, accompanied by considerable involvement of the church community through its local parish structures, religious life communities or Caritas centres (5).
Professionalization of end-of-life care and the marginalization of volunteering
The National Hospice Movement Forum, registered at the beginning of the democratic transformations in 1991, made the volunteers’ voice better heard in ministerial commissions and in the life of society. The effect of the joint efforts of professionals and volunteers, of people of the Church and representatives of secular societies and foundations became the Project of the Development of Palliative and Hospice Care, presented by the Ministry of Health and Social Welfare in 1998. It recognized the significance of voluntary service and spiritual care by incorporating palliative and hospice care in the structures of the healthcare system and safeguarded the funding for home care as well as for the emerging stationary hospices (11). When in 1993 the Ministry of Health and Social Welfare founded the National Council of Palliative and Hospice Care, the voluntary based hospice movement had its representatives inside and was a serious partner in talks for the development of terminal care and the publishing of a final document incorporating palliative and hospice care in the Healthcare system in Poland (12).
Specialist training in palliative care for doctors and nurses was introduced, thus offering specific tools for the functioning of a new field in the healthcare system. Many new home and stationary palliative and hospice care centres were then established throughout the country. Palliative care issues were gradually included in the education system of doctors and nurses as well as psychologists and chaplains, making the dynamic development of care possible through state financing (13). Special emphasis was at that time put on the professionalization of palliative care, in line with the requirements of service providers and the standards adopted in healthcare. This, however, gave rise to tensions between the grassroots hospice movement based on voluntary service, and professional palliative medicine. They were largely due to the use of public funds and a bias in favour of the medical aspects of care, disregarding the others. Fortunately, dialogue and common goals helped to resolve most differences and allowed the development of the care of terminal patients and their relatives to continue (14).
Despite these actions, the amount of volunteers started gradually to diminish in different centres of care, and in some of them volunteer training has stopped, giving more attention to the clinical and medical side of hospice-palliative care (15). This situation has been reported as a lack of a holistic approach, in which apart from professional competence there is an urgent need for good will and enthusiasm of volunteers. Some of our caring institutions were professional but there was no „home-like atmosphere” which was usually created by volunteers caring for patients and their families both in institutional and home care. There was a need to return to the roots and social education was the first step to invite volunteers back into our teams (16).
Compassion through end-of-life volunteering
Since year 2000 charitable institutions in Poland made efforts to promote voluntary service ideas in the Church and the society at large. Caritas established volunteering in schools and parishes, giving a dynamic growth of voluntary service in Poland. Preparation and distribution in all churches of catechetic and homiletic materials for the 60th Charity Week in 2004 devoted to hospice-palliative care helped to promote care of the elderly and terminally ill (4). The National Chaplain of Hospices proposed a new way of talking about hospice service through co-operation with the media and promoting public education about the end of human life. The Hospice Foundation was created and in 2004 a team of professionals and volunteers prepared the first nationwide educational campaign: “Hospice is life, too”. Voluntary service in Poland has started slowly to gain in popularity again and hospice-palliative care centres have searched for new ways of reaching the local communities. Educational programmes, interviews and reports were launched on the main TV channel in Poland, as well as in other national and regional mass media. During one month there were around 1,000 media events regarding hospice-palliative care and end-of-life issues (13). Collaborating with over 100 hospices from all over Poland, and assisted by the mass media, we were able to create discussion regarding end-of-life care and volunteering. As a result of the national hospice campaign, all the hospices noticed the following: a breaking of the taboo concerning end of life issues in the mass media; the consolidation of hospices and palliative care units in Poland and promotion of voluntary service for those in need; and fundraising on a national and local level (4). The second national campaign was successful in public debates and concerts, which were launched during the first International Day of Hospice & Palliative Care around the world. The result of the campaign was a handbook for hospice workers and volunteers, but also for patients and their families (17). This tradition of public education about end-of-life issues continues every year in November, helping to raise awareness and create compassionate communities. Since 2007 subsequent “Hospice is Life, too” public campaigns helped to promote the hospice idea, encouraging new candidates to engage in voluntary hospice service. Hospice centres were often not ready to accept the prospective volunteers and could not prepare them for voluntary hospice service through training. Thus, the idea of the public campaign devoted to voluntary service—arrived, as a result of which hospices throughout Poland have received textbooks for volunteers and have started preparing and training voluntary service coordinators (18). In this way, in Poland, we started creating compassionate communities with the general public and volunteers (17), for whom we were searching in various groups of local community. One of the particular elements of voluntary service in hospice-palliative care is related to an innovative program of involving inmates from correctional facilities to the institutional team care for the people towards the end of their lives. This project will be described below in detail.
Hospice volunteering of prisoners—development of the initiative
Not knowing yet about the concept of Compassionate Communities already developing worldwide (19) we were searching for a new approach to end of life care in our Polish society. After a reconfiguration of services with a return of volunteers, with whom the wider community have been involved we have seen better partnership with professionals. We were exploring further the foundation of our practice experience with community development, policy reform and social and political change, as described by experts in this field (20). Since 2002 the semi-open penal institution and a hospice in Gdansk have cooperated in a project of hospice voluntary work for the convicted. The process of rehabilitation through hospice voluntary work started out of an urgent need of simple labour, but then was enhanced into direct involvement into the patients’ care. We’ve learned in the meantime that end-of-life care has already been offered for years to those living behind bars. The first penitentiary hospice programme was established in US Federal Medical Centre for the convicted in Springfield, Missouri in 1987. Professional systems of prison hospice care were created in the USA and other countries (21). In 1998 the Robert Wood Johnson Foundation initiated a programme called GRACE (Guiding Responsive Action in Corrections at End-of-life) promoting hospice care in penal institutions and prisons. These programmes concentrate on providing help within the penal system, in which the convicted volunteer for aiding their dying inmates (22). As opposed to those projects we were about to introduce convicted criminals into direct care outside of penal institutions, enlarging the existing dimensions of compassionate help in our local community.
In Gdansk, in 2003 an innovative program to reintegrate prisoners into society through voluntary work with hospice patients began. For over a year the presence of prisoners was limited to jobs related to construction, cleaning around the hospice, and no contact with the patients, their families and caring team members was allowed (23). The opportunity to see these people in a different way occurred after a year of cooperation, when one of the young prisoners was admitted to a hospice from a prison hospital. He had a brain tumour and needed constant help and the presence of somebody to reduce his anxiety. His friends from the prison working in the hospice started to visit him as volunteers during their lunch breaks. As they watched over him, coming in turns for 30 minutes, the nurses noticed their care and sensitivity although they were watching them closely and with a lot of fear. In that time an idea was born about training the prisoners to take care of patients. Asked by the hospice, management nurses started to talk about it and agreed to consent. Consequently the hospice team have started collaborating with prison authorities and educational departments on location. Soon after that the most promising and cooperative prisoners from the group were allowed to enter volunteer training after which they were gradually introduced to join teams in caring for patients in the hospice wards. New volunteers in yellow shirts (indicating their new status) began to help patients and medical personnel in the hospice ward. Yellow, the symbol of hope for patients, had a similar meaning for those special voluntary workers (24).
The program of voluntary activities performed by convicts through education and practical actions has been accepted by the hospice team, providing support, limiting the isolation of people suffering from social exclusion towards the end of life. Soon the opportunities for prisoner-volunteer participants to increase their self-acceptance and self-confidence as well as acceptance by others were noticed (25). In Gdansk prisoners were working for 8 hours a day and were receiving no payment, as opposed to other convicts working outside of their penal institution. Good work and commitment in a hospice can help in shortening the sentence, so becoming a part of the hospice voluntary team has started to be seen as a kind of distinction and a reward. The prisoners admit that work in the hospice ennobles them, as one of the hospice team members recalls overhearing a telephone conversation between a prisoner and his mother: “Mum, look, I am not a bad man—I am working in the hospice now. I will send you a picture with the hospice volunteer shirt on me.” (26).
From 2003 to 2008 the hospice in Gdansk was the only institution in Poland, where prisoners were allowed to volunteer directly in patient hospice care. Since 2008 the project has resulted in other hospices in Poland starting cooperation with penal institutions. A distinguishing feature of this awarded project was a nationwide programme called WHAT (hospice voluntary work as a tool of acceptance and tolerance for people leaving penal institutions). This project was based on the experience of cooperation between a prison in Gdansk (a semi-open penal institution) and a hospice in Gdansk. It was aimed at social reintegration of prisoners through voluntary activities in hospices. The hospice personnel and penitentiary counsellors from 20 institutions around Poland were trained how to involve prisoners in hospice voluntary activities and the convicts were acquainted with the aims of hospice-palliative care (27).
The process of rehabilitation through hospice voluntary work in Poland has been appreciated in this country and abroad. In June 2009 Poland was awarded a prestigious prize ‘The Crystal Scales of Justice’ by The European Commission and The Council of Europe for a project called Voluntary Service of the Convicted in Poland implementing an innovative form of cooperation among prisons, hospices and social welfare homes (28). Together with this prize, the new interest of mass media has promoted this idea. Such an unusual presence of people deprived of their freedom in hospice-palliative care centres met with favourable media coverage. In the short time of implementation of the WHAT project many publications appeared in local and national media. The voluntary service of prisoners is present in Polish and foreign press reports, radio and television programmes. In 2008 the German station ARD made a documentary in Gdansk presenting voluntary activities performed by the convicted. In 2009 the French station ARTE made a similar report (29). An important element of increasing social awareness of rehabilitation was an educational film titled “To overcome prejudices”, used as an educational tool in hospices, prisons, but also at universities (30).
Research was needed in order to prove that this method is good for all sides of the existing project. An initial survey conducted by internet users in 2008 clearly demonstrated the social changes in the perception of hospice volunteering. The participants of this survey (the total of 892 votes) had to answer a question if prisoners should have a possibility to work in places like hospices. 61% of respondents said yes, explaining that helping people in need teaches respect for people. Another 32% said yes, especially for prisoners serving short sentences. Only 7% of respondents said no: 4% claimed that a sentence is a form of punishment and should be served in isolation; 3% were of the opinion that it is never known if the prisoners are not going to commit another crime (31). It can be stated that involving prisoners in hospice-palliative teamwork, where they face suffering and death, meet other workers, volunteers and patients’ families, improves their psychosocial functioning (32). After this initial research and good practices from Gdansk and other places in Poland papers have been written for different groups such as researchers and practitioners at penal institutions who were seeing hospice volunteering as a new and promising form of rehabilitation of convicts (33). With time these activities of hospice volunteering prisoners were seen as a tool for social reintegration of persons deprived of their liberty (34), and more research was needed in order to understand what is happening to these new volunteers helping those in need and helping themselves to find a new place in the local community after committing crimes and being deprived of freedom.
The search for meaning of life among prisoner-hospice volunteers
The famous neurologist and psychiatrist from Vienna Victor E. Frankl, a man who experienced extreme isolation and deprivation in an Auschwitz concentration camp as a holocaust survivor, created logotherapy. He defined the meaning of life as a subjective condition of satisfaction associated with intentional actions directed at values. A human being is not the creator of meaning but discovers it in reality, and the meaning of life is not obtained once and forever but has to be discovered throughout the whole of life along with new emerging life events (35). The meaning of life is closely connected to its meaninglessness. According to Frankl, the meaninglessness of life is a situation when the understanding of the meaning of life decreases as a result of barriers in achieving selected values. Personality factors and external situations, such as death of one’s loved ones, losing a job or isolation, may cause internal crises and the feeling of senselessness. A manifestation of the meaninglessness of life may be running away from home, drug addiction, alcoholism or crime. If the selected values do not belong to the primary ones, a person will live a superficial life, believe in pseudo-meanings of life, which will collapse when confronted with oncoming difficulties. Being faithful to one’s own values sets in order all human activities, provides a person with a feeling of safety and protects them from getting lost in life (34).
It is obvious that the time of imprisonment is a specific period in a prisoner’s life, which brings a lot of changes in their life. During this time they adapt to new social roles, evaluate their lives, value things, give meaning to past events and often set new goals. Serving a sentence is a difficult situation and as such may be the time of searching for the meaning of life and changing perspectives on life priorities. In psychology the meaning of life is one of the basic existential needs connected with the personal and subjective experience of life, as it was written in the introduction to a research paper regarding convicts as hospice volunteers (36). The purpose of the study undertaken by a Gdansk hospice team was to characterize the meaning of life among prisoners doing voluntary work for a hospice, and those not involved in volunteering, but working outside the same penal institution. Research was conducted by measuring the qualitative characteristics of the meaning of life among the prisoners involved in the study. Fourteen convicts have participated in this study, 7 of them were the convicts of the penal institution, not involved in hospice volunteering, and other 7 men, were the convicts of the same penal institution, volunteering for the Hospice in Gdansk.
The research concluded that prisoners performing hospice-palliative care voluntary activities indicate a diverse range of life goals such as: family, work, development, health and happiness, and describe them using various adjectives. They concentrate on the future, as they seldom refer to leaving prison, and in this aspect they differ from the prisoners not involved in hospice volunteering. In their responses the prisoners—volunteers often refer to the area of feelings and relationships. They can admit to their weaknesses, difficulties and dreams connected with the presence of another person. It can be said that the majority of them do their best to look realistically at their lives, which increases their chances to cope effectively with their future problems. These elements are less noticeable in the group of prisoners not involved in volunteering. The authors conclude that the phenomenon of voluntary work may prove to be important in the context of understanding the meaning of life and in the process of positive changes in the behaviour of the prisoners after having finished serving their sentences (37).
The next phase of this research was initiated in 2017 and its findings were presented during the 15th EAPC World Congress: Progressing Palliative Care. Innovative work from Poland in which prisoners are trained to work as compassionate carers of vulnerable people in hospices and nursing homes started in 2003 and has spread to over 40 palliative care facilities in Poland. Initial research showed that the majority of prisoners—volunteers look realistically at their lives, which increases their chances of coping effectively with future problems. These elements are less noticeable in the group of prisoners not involved in volunteering. Years of experience in hospice-palliative care volunteering programmes for prisoners make it possible to claim that the presence of dying, experienced in everyday hospice reality, may influence changes in the value hierarchy and life goals of the convicted. The phenomenon of voluntary work may prove to be important in the context of understanding the meaning of life and in the process of positive changes in the behaviour of the prisoners after serving their sentence (38). New elements of this research and more detailed analysis will be soon presented in a separate research publication, giving yet another insight into compassionate care for our local communities.
Over many years the project of hospice volunteering of prisoners in Poland has helped to break down stereotyping and the perceptions of prisoners, starting with the Gdansk experience, where they gradually became full members of a care team, and then other teams which continue this cooperation in their local communities. Over 600 prisoners have passed through the hospice in Gdansk in over 10 years of cooperation. They often admit that work in the hospice ennobles them (39). Convicts, who are mostly doing time on charges of burglary, non-payment of alimony and petty crime, see working in the hospice as a chance to change their attitudes. They see a different world, in which compassion and understanding for other people are most important. Some volunteer prisoners, after their release from a correctional facility, have been employed by the hospice in Gdansk. It is believed that such places as a hospice, where we undergo extreme experiences, can provide more radical answers to questions regarding our own attitudes. The initial data has showed that those who work in hospices receive better results in re-education and have the chance to receive a reduction of their sentence. Thanks to the correctional programs prisoners are currently working in over 40 hospices and more than 70 nursing homes, helping patients in the need of everyday care. In the future the convicted men and women from semi-open and open penal institutions could be directed to volunteer for hospitals or children’s homes (40). Compassionate communities could learn from these experiences and reach out to others who are deprived of full freedom or a right to work, such as migrants, refuges or asylum seekers, who could give back to local communities hosting them. Prisoners who proved to be effective hospice volunteers could be an inspiration to all those who want to reach out to new people in order to make end-of-life care more social, more humane and a more universal duty of our compassionate communities.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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