Providing emergency-only hemodialysis to undocumented immigrants with life-threatening renal failure is associated with greater moral distress and professional burnout in clinicians who practice in safety-net hospitals, according to a study published in the Annals of Internal Medicine.1

Investigators enrolled interdisciplinary physicians (n=27), nurses (n=16), and allied health professionals (n=7) who reported ≥1 year emergency-only hemodialysis treatment experience of undocumented immigrants in a safety-net setting. Participants underwent semi-structured interviews focused on discovering moral, ethical, and professional themes and subthemes associated with providing emergency-only hemodialysis care to undocumented immigrants. High-level themes consistently identified during the interviews included professional burnout, moral distress from promoting injustice, confusing and perverse financial incentives, and inspiration toward advocacy.

Daily organizational and systemic-level barriers for providing care were the primary drivers of professional burnout. Many physicians reported emotional exhaustion from observing patients’ suffering and high mortality, and some physicians discussed falsely appearing uncaring toward visibly ill patients when they were forced to deny treatment in emergency-only hemodialysis patients. In addition, physicians reported having to work longer hours “to make up for the unfairness they perceived their emergency-only hemodialysis patients faced,” and many reported feeling confused regarding the eligibility criteria for emergency-only hemodialysis.

Continue Reading

Moral distress, another principal theme that emerged from the interview analyses, was partly driven by the perceived need for increasing the number of emergency-only hemodialysis patients treated rather than improving the quality of the care. In addition, some participants reported that patients had intentionally altered their own laboratory values in an effort to become eligible for emergency-only hemodialysis, such as eating foods high in potassium in order to elevate values.

Related Articles

Furthermore, considering that undocumented immigrants often perform the most physically demanding jobs with the lowest pay wage, denying these patients’ care based on vague eligibility criteria may be another driver for moral distress in physicians providing emergency-only hemodialysis.

The confusing state of emergency-only hemodialysis with regard to financial incentives was also often reported during the interviews. For instance, participants frequently reported an inability to see the cost benefit of using emergency-only hemodialysis over standard hemodialysis, particularly with the use of screening resources such as blood tests, chest radiography, and electrocardiography. In addition, participants did not appear to know whether the hospital improved their revenue stream with the use of emergency-only hemodialysis vs standard care.  

Inspiration toward advocacy was perhaps the most positive theme observed in the study. Patients’ kindness, resilience, and gratitude often inspired healthcare providers. Caring for these patients reinforced a sense of decency and motivation toward greater advocacy for at-risk immigrant patients.

According to an accompanying editorial2 by Ashwini R. Sehgal, MD, of Case Western Reserve University in Cleveland, Ohio, this study provides a potential argument for the establishment of universal healthcare for anyone within the US borders. Dr Sehgal also believes the dialysis community should “consider successful approaches from other parts of the country, such as sharing the costs of caring for undocumented patients, lobbying for additional Medicaid benefits, identifying tax revenues, and helping patients buy health insurance” in order to address the current issues associated with emergency-only hemodialysis.


  1. Cervantes L, Richardson S, Raghavan R, et al. Clinicians’ perspectives on providing emergency-only hemodialysis to undocumented immigrants: a qualitative study [published online May 21, 2018]. Ann Intern Med. doi:10.7362/M18-0400
  2. Sehgal AR. Dialysis without borders [published online May 21, 2018]. Ann Intern Med. doi:10.7362/M18-1267