Physicians report feeling moral distress over hospital policies that force inadequate care based on immigration status

1. Physicians working in settings that provide emergency only hemodialysis (EOHD) reported higher rates of professional burnout.

2. Physicians providing EOHD reported feeling moral distress regarding inadequate care based on immigration status and inspiration towards further patient advocacy.

Evidence Rating Level: 2 (Good)

Study Rundown: In the United States, the policy for undocumented immigrants with end-stage kidney disease often involves EOHD. This policy means that patients must be evaluated in the emergency department and be determined to be critically ill before funds from the Medicaid program will be released for hemodialysis. EOHD has been associated with higher rates of mortality and psychosocial distress in patients. The purpose of this study was to evaluate physicians’ responses to such a process. This study has several limitations. First, the study was conducted in only two safety net systems, and it may not be applicable to other training environments. Furthermore, there may have been an inherent response bias from participants, where negative experiences and perceptions were minimized due to social desirability. Strengths of this study include that it looked to evaluate clinicians’ experiences with this policy, rather than only the patients’ experiences. This study emphasized the importance of re-evaluating the EOHD policy due to the negative impact it has on both patients and healthcare providers.

Click to read the study in Annals of Internal Medicine

Relevant Reading: The Illness Experience of Undocumented Immigrants  With End-stage Renal Disease 

In-Depth [qualitative study]: The authors conducted a qualitative study using semi-structured interviews. Results were then analyzed by thematic analysis, generating themes and subthemes. A total of fifty interdisciplinary clinicians providing EOHD in the Houston, Texas or Denver, Colorado safety net were interviewed. Preliminary findings were sent back to participants and feedback was incorporated into the final analysis. With respect to results, four major themes were derived from the process: (1) Moral distress from propagating injustice, (2) physician burnout, (3) confusing and perverse financial incentives, and (4) inspiration for patient advocacy. The mean age of the participants was 53 years (SD, 10) and the mean number of years of clinical experience with EOHD was 8.7 (SD, 7.9).

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