Annals of Internal Medicine
Volume 169, Issue 2, 2018, Pages 78-86

Clinicians' perspectives on providing emergency-only hemodialysis to undocumented immigrants: A qualitative study (Review)

Cervantes L.* , Richardson S. , Raghavan R. , Hou N. , Hasnain-Wynia R. , Wynia M.K. , Kleiner C. , Chonchol M. , Tong A.
  • a Denver Health, University of Colorado, Denver, CO, United States, Denver Health, MC 4000, 777 Bannock, Denver, CO 80204, United States
  • b Denver Health, Denver, CO, United States, Denver Health, 601 Broadway, Denver, CO 80204, United States
  • c Harris Health, Baylor College of Medicine, Houston, TX, United States, Baylor College of Medicine Medical Center, 7200 Cambridge Street, Houston, TX 77030, United States
  • d University of Texas McGovern Medical School, Houston, TX, United States, University of Texas McGovern Medical School, 3011 Bell Street, Houston, TX 77003, United States
  • e Denver Health, Denver, CO, United States, Denver Health, MC 6551, 777 Bannock Street, Denver, CO 80204, United States
  • f Denver Health, University of Colorado, Denver, CO, United States, University of Colorado, Anschutz Medical Campus, Mail Stop B 137, 13080 East 19th Avenue, Aurora, CO 80045, United States
  • g Denver Health, Denver, CO, United States, 3921 Lions Paw Street, Castle Rock, CO 80104, United States
  • h Denver Health, University of Colorado, Denver, CO, United States, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Mail Stop C281, 12700 East 19th Avenue, Aurora, CO 80045, United States
  • i University of Colorado, Denver, CO, United States, University of Sydney, Sydney, Australia, Children's Hospital at Westmead, Westmead, NSW, Australia, Centre for Kidney Research, Children's Hospital at Westmead, Corner Hawkesbury and Hainsworth Street, Sydney, NSW 2145, Australia

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. © 2018 American College of Physicians.

Author Keywords

[No Keywords available]

Index Keywords

Safety-net Providers personal experience perception Social Desirability human middle aged priority journal Physicians qualitative research Undocumented Immigrants health personnel attitude interview Attitude of Health Personnel United States Humans undocumented immigrant psychology Trust burnout Interviews as Topic male semi structured interview female hemodialysis Renal Dialysis Review clinical article emotional stress safety net hospital emergency care Kidney Failure, Chronic adult physician hospital emergency service Emergency Service, Hospital chronic kidney failure Health Services Accessibility Texas health care delivery Colorado
Link
https://www.scopus.com/inward/record.uri?eid=2-s2.0-85050377045&doi=10.7326%2fM18-0400&partnerID=40&md5=5d894a97db527dd39596be5a054ea2d5
DOI: 10.7326/M18-0400
ISSN: 00034819
Cited by: 13
Original Language: English