Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative Study

Abstract

Background: In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure ("emergency-only hemodialysis" [EOHD]). These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing EOHD affects the clinicians involved.

Objective: To understand clinicians' experiences providing EOHD.

Design: Qualitative study using semistructured interviews.

Setting: A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas.

Participants: Fifty interdisciplinary clinicians experienced in providing EOHD.

Measurements: Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes.

Results: Four themes and 13 subthemes (in parentheses) were identified: 1) drivers of professional burnout (emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over EOHD criteria, and physical exhaustion from overextending to bridge care), 2) moral distress from propagating injustice (altered care based on nonmedical factors, focus on volume at the expense of quality, and need to game the system), 3) confusing and perverse financial incentives (wasting resources, confusing financial incentives, and concerns about sustainability), and 4) inspiration toward advocacy (deriving inspiration from patients and strengthened altruism).

Limitation: Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences.

Conclusion: Clinicians in safety-net settings who provide EOHD to undocumented patients describe experiencing moral distress and being driven toward professional burnout. The burden of EOHD on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need.

Primary funding source: Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.