Clinicians ethically challenged when it comes to caring for undocumented immigrants

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In one of the first studies to explore clinician moral distress related to the ethically challenging issue of providing healthcare to undocumented immigrants, researchers from Regenstrief Institute and Indiana University School of Medicine surveyed physicians and nurses to assess their perspectives on treating end-stage renal disease in such immigrants.

This is a condition that Medicare covers for U.S. citizens regardless of age, but does not cover for undocumented immigrants.

Moral distress is an emotional experience in which an individual feels constrained from acting on deeply held beliefs, resulting in the sense of compromising one's professional integrity. Moral distress has been correlated with traumatic stress, emotional exhaustion, burnout, depression, and intent to leave a position or profession.

Nearly half (48%) of the clinicians surveyed in the new study indicated experiencing moral distress when required to provide only last-resort emergent dialysis for end-stage kidney disease for undocumented immigrant patients, rather than the standard care of thrice-weekly intensive dialysis sessions covered by Medicare for U.S. citizens.

WHAT'S THE IMPACT

Under federal regulations, individuals, including those who are undocumented, cannot be refused care in an emergency department if they meet certain disease advancement criteria. In the majority of states, undocumented immigrants with end-stage renal disease receive only emergency dialysis. 

Clinical outcomes for undocumented immigrants receiving emergent dialysis show higher death rate, increased length of stay and poorer quality of life than outcomes for those receiving standard dialysis three times a week.

The most common factor contributing to moral distress in the provision of care to undocumented immigrants needing dialysis, cited by survey respondents, was the suffering of patients due to inadequate dialysis treatment. Other factors contributing to clinician moral distress included feeling constrained by laws and policies and being unable to act in the best interest of the patient.

Authors of the study said what's needed are innovative solutions, changes in law and policy, and a greater emphasis on prevention – including blood pressure control, diabetes care and other strategies for end-stage renal disease – in all populations and subgroups.

Half of the survey respondents were doctors (attending physicians, fellows or residents) including internists, nephrologists, emergency medicine, critical care and palliative care specialists. The other respondents were overwhelmingly medical-surgical nurses. The mean age of all survey participants was 39 years old. Nearly two-thirds of respondents were female.

"Providing substandard care in the form of emergent dialysis to patients with chronic kidney disease profoundly impacts the well-being of providers," said study first author Dr. Areeba Jawed, who trained in internal medicine, nephrology, palliative care and clinical ethics at IU School of Medicine. "We must talk about these ethically challenging issues collectively to prevent moral injury and burnout in providers."

THE LARGER TREND

Add moral distress to the long list of reasons clinicians are experiencing burnout in today's healthcare environment. Burnout, disengagement and the resulting staff shortages were cited in a March survey as being the most potentially disruptive forces facing hospitals and health systems in the next three years.

The pandemic is taking a toll on the mental and emotional wellbeing of physicians, with female physicians and those in critical care and infectious disease reporting the highest burnout rates during the public health emergency, according to findings from a December physician burnout report from Medscape.

Burnout and the stress of the pandemic – including factors such as personal risk, social distancing and financial uncertainty – appeared to diminish physicians' overall work life happiness, with only 49% reporting they were happy in 2020, versus 69% pre-pandemic. More than one-third (34%) reported feeling unhappy last year, compared with 19% in 2019.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com