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Doctors distressed by 'unethical' dialysis rules for undocumented immigrants

(Reuters Health) - Doctors who take an oath to ‘do no harm’ are morally distressed by dialysis payment policies in many U.S. states that don’t cover services for undocumented immigrants until they’re near death, a new study found.

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.

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: Annals of Internal Medicine, online May 21, 2018.