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Physicians report distress, burnout about providing emergency-only dialysis to undocumented immigrants

Hospital policies that prevent physicians from providing hemodialysis to undocumented immigrants with end-stage kidney disease except in emergency cases cause physicians to feel moral distress and drive them toward burnout, according to findings published in Annals of Internal Medicine.

“In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an [ED] and are found to have life-threatening renal failure (“emergency-only hemodialysis”),” Lilia Cervantes, MD, from Denver Health and University of Colorado, and colleagues wrote. “These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing [emergency-only hemodialysis] affects the clinicians involved.”

To better understand its effects on physicians, Cervantes and colleagues interviewed 50 interdisciplinary clinicians who directly cared for undocumented immigrants requiring emergency-only hemodialysis for at least 1 year about their experiences providing emergency-only hemodialysis. Participants included 27 physicians, 16 nurses and seven allied health professionals. The researchers studied the interviews to determine themes of participants’ views regarding emergency-only hemodialysis.

Cervantes and colleagues identified four major themes about physicians’ experiences with emergency-only hemodialysis.

The first theme was drivers of physician burnout. Physicians reported feeling emotionally exhausted from seeing patients suffer and die unnecessarily and physically exhausted from overextending to bridge care. They also reported feeling like they were compromising trust and engagement with patients. Additionally, physicians felt like they had no control over criteria for emergency-only hemodialysis.

The second theme was moral distress from discrimination. Clinicians reported feeling like they needed to modify care and neglect quality due to nonmedical factors.

The third theme was irrational financial incentives. Participants were concerned about wasting resources and sustainability.

The last theme was inspiration toward advocacy. Physicians reported being inspired by patients to advocate for their care.

“Clinicians in safety-net settings who provide [emergency-only hemodialysis] to undocumented patients describe experiencing moral distress and being driven toward professional burnout,” Cervantes and colleagues concluded. “The burden of [emergency-only hemodialysis] on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need.”

In an accompanying editorial, Ashwini R. Sehgal, MD, from Case Western Reserve University, wrote that emergency-only hemodialysis is not as effective as standard dialysis three times a week and costs substantially more.

Sehgal suggested the use of universal health coverage that attends to everyone within the borders of the United States. New treatment mechanisms should be created in states that do not offer standard dialysis to undocumented immigrants, according to Seghal.

“National, state, and city borders are man-made creations that often ignore cultural, historical, and geographic connections among populations,” he wrote. “Such borders should not define the line between life and death for patients with [end-stage kidney disease].” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.