“Emergency-Only Dialysis” Policy Puts Burdens on Clinicians

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Following emergency-only hemodialysis (EOHD) policies for undocumented immigrants causes moral distress and may contribute to burnout among healthcare professionals at safety-net hospitals, reports a qualitative study in Annals of Internal Medicine.

The researchers interviewed 50 physicians, nurses, and other clinicians at safety-net hospitals/systems in two cities (Denver and Houston) that provided a high volume of EOHD for undocumented patients. Thematic analysis was performed to describe the experiences and perspectives of clinicians providing this type of care.

Four major themes were identified. Emergency-only dialysis policies contributed to drivers of professional burnout, with healthcare professionals experiencing emotional exhaustion related to patients’ “needless suffering” and high mortality. Clinicians felt they had to “emotionally dissociate” themselves due to a policy that was not under their control. They also reported mortal distress related to EOHD policies. All participants felt that it was unethical to make care decisions based on nonmedical factors, and felt justified in “bending the rules.”

Clinicians were frustrated over the “confusing and perverse” financial incentives associated with EOHD, which they viewed as an inefficient and unsustainable use of hospital and system resources. Despite their distress and frustrations, the healthcare professionals felt inspired by their patients’ resilience, kindness, and gratitude. Clinicians felt that working with these patients provided them an opportunity to act according to their best instincts and “motivated them to advocacy.”

In many states, undocumented immigrants with ESRD do not receive dialysis until they develop life-threatening renal failure. This EOHD policy leads to high mortality and distress for patients, but little is known about its impact on clinicians.

“The burden on clinicians of providing EOHD should inform policy discussions and systemic approaches to support provision of an adequate standard of care to all patients with ESKD,” the investigators said. [Cervantes L, et al. Clinicians’ perspectives on providing emergency-only hemodialysis to undocumented immigrants: a qualitative study. Ann Intern Med 2018; DOI: 10.7326/M18-0400].