Kidney Docs Worry Over No Dialysis for Undocumented Immigrants
Undocumented immigrants in the United States are often denied treatment for kidney failure until they have a life-threatening emergency. Now a new study finds that the doctors and nurses who treat them are frustrated and demoralized over it.
At issue is access to treatment for end-stage kidney disease -- in which the kidneys can no longer perform their job of removing excess water and waste from the body.
The standard of treatment is dialysis three times a week: The treatment passes the patient's blood through a machine that filters it as the kidneys would.
But in the United States, undocumented immigrants often cannot undergo dialysis, because they don't qualify for standard Medicaid or the federal dialysis entitlement program set up in the 1970s.
Instead, they can only get dialysis when they land in an emergency room at death's door, explained study lead author Dr. Lilia Cervantes, a hospitalist with Denver Health in Colorado.
The consequences are obvious, Cervantes said. When the kidneys stop working, fluids build up in the body, including the lungs, she explained.
"People arrive in the emergency room feeling like they're drowning," she said.
Excess potassium is another life-threatening complication. When potassium builds up in the blood, it can send the heart into cardiac arrest -- which is fatal within minutes without emergency medical care.
Such "emergency-only" dialysis carries a 14-times higher death rate, compared to standard dialysis, Cervantes said. Beyond that, she added, the process causes debilitating physical and emotional stress for patients and their families.
The new study reveals another consequence: the strain put on doctors and nurses.
In interviews with providers at two U.S. hospitals, Cervantes' team found widespread guilt, exhaustion and "moral distress" over the care given to undocumented immigrants.
Doctors and nurses were emotionally drained from seeing "needless suffering and high mortality," Cervantes said.
At the same time, some also said they tried to "numb" themselves against feeling too much, because they were powerless to change anything.
"Turning patients away from hemodialysis is a huge aspect of physician burnout," one physician said. "Residents have to emotionally disassociate from their patients, and that's the opposite of what we're trying to teach."
Both hospitals in the study were "safety net" hospitals -- meaning they are legally obligated to provide care regardless of whether patients can pay.
And the providers there "uniformly" believed it was unethical to base medical care on a person's social status, Cervantes said.
So some admitted to "gaming the system." On records, they would exaggerate symptoms or lab results, so that a patient could qualify for emergency dialysis.
Yet those tactics also left providers worried about their personal integrity, the study found.
"This study shows that providing emergency-only dialysis is harmful not only to patients, but also to the physicians and nurses who take care of them," said Dr. Ashwini Sehgal, a professor of medicine at Case Western Reserve University in Cleveland.
He wrote an editorial published with the findings May 21 in the Annals of Internal Medicine.
To Sehgal, it's clear that a national policy change is in order. But, he said, since any such move would take time, states and cities could act in the interim.
Some states, such as Arizona, California and New York, have already made changes to their Medicaid programs to fund standard dialysis for undocumented immigrants. In Arizona, for example, the administrative code was altered to include regular outpatient dialysis as an "emergency service," according to Cervantes.
"I'm not sure if all states realize they can make those changes," she said.
The incentives to do so go beyond providing humane treatment, Cervantes said. Studies show that emergency-only dialysis is four times more costly than standard care -- and it uses up scarce ER resources and hospital beds.
Cervantes said she hopes this study raises awareness outside the kidney disease field.
"We are all stakeholders in this," she said. "How can we come together to advocate for these most vulnerable patients?"
An estimated 6,500 undocumented immigrants in the United States have end-stage kidney disease, according to Cervantes' team. A number of other countries -- including Canada, Germany and Italy -- provide regular dialysis to undocumented immigrants, Sehgal said.
One argument against doing so is that people would start crossing borders specifically seeking dialysis. However, Sehgal said, there is no evidence that has happened in places that already fund standard dialysis.
The National Kidney Foundation has more on kidney disease and dialysis.
SOURCES: Lilia Cervantes, M.D., hospitalist, Denver Health, and associate professor of medicine, University of Colorado Health Sciences Center, Denver; Ashwini Sehgal, M.D., professor of medicine, Case Western Reserve University School of Medicine, Cleveland; May 21, 2018, Annals of Internal Medicine