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Doctors suffer from "unethical" dialysis regulations for undocumented immigrants



(Reuters Health) – Doctors swearing the oath of "no harm" are morally oppressed in many states because they offer no services to undocumented immigrants until they are about to die, one said new study.

An estimated 6,500 undocumented immigrants in the US have end-stage renal disease (ESKD) and many, according to a report, can not receive routine dialysis to keep them alive under annuities under payment policy that only covers these treatments in an emergency internal medicine.

Beyond life-cycle casualty rates and increased costs, the payment guidelines, which only allow emergency dialysis for undocumented immigrants, put doctors in an impossible ethical position and contribute to dissatisfaction and burnout, say the authors.

"Undocumented immigrants relying on emergency-only hemodialysis for weeks are critically ill and critically ill, so we create personalized relationships with the patients and their families," said lead author. 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 via email. "Unfortunately we are also invited to their funerals."

Compared with routine dialysis, which can keep some patients alive for years, people who only receive emergency dialysis with ESKD when in critical condition have a 1

4-fold higher mortality rate, researchers note. Emergency dialysis is also nearly four times more expensive than routine dialysis.

"It is emotionally distressing to experience needless suffering and high mortality," said Cervantes.

Humans rely on the kidneys to filter blood and remove excess fluid and toxins from the body in the form of urine. If the kidneys fail, people can survive days to a few weeks unless they receive a transplant or start dialysis.

During hemodialysis, a machine filters blood four times a week for four hours to remove excess fluid and toxins. Undocumented immigrants are the only subset of patients in the US who can not cover this type of dialysis with programs such as Medicare or Medicaid. Therefore, they are only covered if the states provide funds for this care.

When patients only receive emergency dialysis, they can arrive at the hospital in shortness of breath and complain of drowning because so much fluid has accumulated in their bodies, Cervantes said. Sometimes they suffer from nausea, vomiting and confusion or require cardiopulmonary resuscitation (CPR) due to the abnormal heart rhythm.

For the study, Cervantes and colleagues surveyed 50 physicians – including doctors, nurses, and other health professionals – on how providing emergency dialysis has affected their feelings about the practice of medicine.

Clinicians reported that they felt emotionally and physically depleted by daily organizational and systemic barriers to care. In addition, they were affected by unnecessary suffering and high mortality.

They also considered it unethical to provide inferior treatment to patients because of their immigration status, and were frustrated by the payment policy, which made it impossible to give all patients equal access to quality treatment.

The study provides new evidence that denying dialysis treatment to undocumented immigrants leads to burnout, moral stress and discomfort over financial incentives that discourage patients from receiving necessary care. 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 dialysis on physicians and nurses," said Sehgal, author of an accompanying editorial, via e-mail. "It was surprising to learn that only dialysis is bad, not only for patients, but also for doctors and nurses."

SOURCE: bit.ly/2IFwsHe Annals of Internal Medicine, online May 21, 2018.


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