According to a study, researchers followed the policies that allow undocumented immigrants to obtain hemodialysis only in emergencies hurt more than the patients themselves. The policies also take a toll on clinicians who feel forced to provide what they view as substandard care. The study was published in the Annals of Internal Medicine.

Moral distress, burnout, and frustration with inconsistent financial incentives were common themes shared by healthcare personnel from two safety net hospitals during study interviews. A study confirms others that have found that clinicians providing care for patients with complex needs in safety-net settings face high rates of professional burnout and that insufficient resources for patient care is a primary source of stress.

Another issue highlighted in this study is "the unintended consequences and ethical dilemmas health care policy can generate," Cervantes and colleagues add. These clinicians "regularly struggled to reconcile ethical principles of justice, beneficence, veracity, and respect for autonomy in a policy environment they believed supported none of these values." The findings should "inform discussions of systemic approaches to support the provision of adequate care based on medical need.

Thousands of Patients in the United States Rely on EOHD

It is estimated that 6500 undocumented immigrants in the United States suffer from end-stage kidney disease, with half of those patients living in jurisdictions that require them to obtain EOHD. Hemodialysis policies and protocols for undocumented immigrants vary by state, the authors explain. Some states, such as Arizona and California, allow for the provision of standard outpatient dialysis to this population.

Others, including Colorado and Texas, restrict their access to EOHD, and only when the patient meets criteria for an emergent, life-threatening illness, such as severe hyperkalemia, volume overload, or uremia. The interviewees came from a variety of disciplines, including physicians (n=27), nurses (n=16), and allied health professionals (n=7). They had a mean age of 53 years (standard deviation [SD], 10), and included 31 female clinicians (62%). They had a mean of 8.7 years (SD, 7.9) of clinical experience providing EOHD.

Clinicians also described anger at feeling forced to deny EOHD even when patients appeared quite ill. Along with prolonging the patients' suffering, the clinicians believed such denials made them appear callous or uncaring and chipped away at their patients' trust in them, which they described as "demoralizing." The respondents also reported struggling with moral distress from feeling forced to make decisions based on nonmedical factors, which they perceived as unethical.

To compensate, they sometimes resorted to "bending the rules," but this then "made them worry about their integrity." Other common sources of frustration cited by the interviewees were the confusing and often "perverse" financial incentives. Not only is EOHD more expensive than standard hemodialysis, but forcing patients to go to the emergency department often meant wasting other resources as well. The clinicians expressed uncertainty over the financial policies supporting the provision of EOHD and wondered whether the system was sustainable.