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 An estimated 6,500 undocumented immigrants in the U.S. have
end-stage kidney disease (ESKD) and many of them can't receive
routine dialysis to keep them alive under payment policies that only
cover these treatments in an emergency, according to a report in the
Annals of Internal Medicine.
Beyond the toll in patient lives and increased costs, payment
policies that allow only emergency dialysis for undocumented
immigrants are putting doctors in an impossible ethical position and
contributing to job dissatisfaction and burnout, the authors say.
"Undocumented immigrants that rely on emergency-only hemodialysis
are near-death and critically ill weekly and so we form personalized
relationships with the patients and their families," said lead
author Dr. Lilia Cervantes of Denver Health and the University of
Colorado School of Medicine.
"We are invited to their weddings, quinceaneras, and other family
events because they become friends," Cervantes said by email.
"Sadly, we are also invited to their funerals."
Compared with routine dialysis, which can keep some patients alive
for years, people who with ESKD who receive only emergency dialysis
when they're in critical condition have a 14-fold higher mortality
rate, researchers note. Emergency-only dialysis is also nearly four
times more expensive than routine dialysis.
"It is emotionally distressing to witness needless suffering and
high mortality," Cervantes said.
People rely on the kidneys to filter blood and remove excess fluid
and toxins from the body in the form of urine. When the kidneys
fail, people may survive days to a few weeks unless they receive a
transplant or start dialysis.
During hemodialysis, a machine filters the blood for four hours
three times per week to remove the excess fluid and toxins.
Undocumented immigrants are the only subset of patients in the U.S.
who can't get this type of dialysis covered by programs like
Medicare or Medicaid, and as a result they're only covered if states
set aside funds to pay for this care.
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When patients can only get emergency dialysis, they may arrive at
the hospital short of breath and complaining of a drowning sensation
because so much fluid has accumulated in their bodies, Cervantes
said. Sometimes they suffer from nausea, vomiting and confusion or
require cardiopulmonary resuscitation (CPR) because of the abnormal
heart rhythm.
For the study, Cervantes and colleagues surveyed 50 clinicians -
including doctors, nurses and other health professionals - about how
providing emergency-only dialysis had impacted their feelings about
practicing medicine.
Clinicians reported that they felt emotionally and physically
exhausted by daily organizational and system-level barriers to
providing care. In addition, they were troubled by witnessing
unnecessary suffering and high mortality.
They also felt it was unethical to provide substandard care to
patients based on their immigration status and frustrated by payment
policies that made it impossible to give all patients equal access
to high quality treatment.
The study offers fresh evidence that denial of dialysis care to
undocumented immigrants contributes to clinician burnout, moral
distress, and discomfort about financial incentives that stop
patients from getting needed care, said Dr. Ashwini Sehgal, of
MetroHealth Medical Center and Case Western Reserve University in
Cleveland, Ohio.
"This is the first study to examine the impact of emergency only
dialysis on physicians and nurses," Sehgal, author of an
accompanying editorial, said by email. "It was surprising to learn
that emergency only dialysis is bad not just for patients but also
for physicians and nurses."
SOURCE: http://bit.ly/2IFwsHe Annals of Internal Medicine, online
May 21, 2018.
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