Physicians report moral distress over ‘emergency-only’ hemodialysis for undocumented immigrants

Clinicians in safety-net hospitals reported moral distress and professional burnout because of policies that prevent them from offering hemodialysis to undocumented immigrants except in an emergency, a study found.

In the U.S., nearly half of undocumented immigrants with end-stage kidney disease (ESKD) receive hemodialysis only when they have life-threatening renal failure, called “emergency-only” hemodialysis. Researchers conducted one-to-one in-person interviews with clinicians in safety-net hospitals in Denver and Houston to determine how physicians feel about the issue. Twenty-seven physicians, 16 nurses, and seven allied health professionals were interviewed. Findings from the qualitative study were published May 22 by Annals of Internal Medicine.

Clinicians reported emotional and physical exhaustion from daily organizational and system-level barriers to providing care. In addition, they were troubled by witnessing unnecessary suffering and high mortality. Four themes and 13 subthemes were reported:

• drivers of professional burnout: emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over emergency-only hemodialysis criteria, and physical exhaustion from overextending to bridge care;
• moral distress from propagating injustice: altered care based on nonmedical factors, focus on volume at the expense of quality, and the need to game the system;
• confusing and perverse financial incentives: wasting resources, confusing financial incentives, and concerns about sustainability; and
• inspiration toward advocacy: deriving inspiration from patients and strengthened altruism.

The researchers concluded that emergency-only hemodialysis harms clinicians who are forced to provide inadequate care to their patients. They wrote, “In summary, a diverse group of experienced clinicians in safety-net settings reported experiencing several important drivers of professional burnout from providing [emergency-only hemodialysis] to undocumented patients and moral distress from feeling compelled to perpetrate injustice and provide inferior care due to a nonmedical factor (immigration status).”

An accompanying editorial called for a two-pronged solution that first advocated for universal health coverage and comprehensive immigration reform. The editorial also recommended that the dialysis community in cities and states that do not provide standard dialysis to undocumented patients should work together to create broader treatment systems.

“National, state, and city borders are man-made creations that often ignore cultural, historical, and geographic connections among populations,” the editorial stated. “Such borders should not define the line between life and death for patients with ESKD.”