Clinicians are ethically challenged when it comes to caring for undocumented migrants


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In one of the earliest studies to examine the moral burden placed on clinicians in the context of the ethically challenging health care issue for undocumented immigrants, researchers from the Regenstrief Institute and Indiana University School of Medicine asked doctors and nurses about their perspectives on treating kidney disease in the terminal stages to judge such immigrants.

This is a condition Medicare covers for US residents regardless of age, but not for undocumented immigrants.

Moral distress is an emotional experience in which a person feels prevented from acting on ingrained beliefs, leading to a feeling of compromising professional integrity. Moral stress has been correlated with traumatic stress, emotional exhaustion, burnout, depression, and an intention to leave a position or job.

Almost half (48%) of the clinicians surveyed in the new study said they felt moral need if they only had to offer emergency dialysis for end-stage kidney disease to undocumented migrant patients as a last resort, rather than the standard treatment of three times weekly intensive dialysis Medicare Covered Sessions for US Citizens.


According to federal regulations, people, including undocumented people, cannot be refused emergency room treatment if they meet certain disease progression criteria. In most states, undocumented migrants with end-stage renal disease are only given emergency dialysis.

Clinical results for undocumented migrants on emergency dialysis show higher death rates, longer lengths of stay, and poorer quality of life than results for those on standard dialysis three times a week.

The factor most cited by respondents as adding to the moral burden of caring for undocumented immigrants on dialysis was patient suffering from inadequate dialysis treatment. Other factors that contributed to the moral burden on clinic staff were a feeling of being restricted by laws and guidelines and unable to act in the best interests of the patient.

The authors said innovative solutions, law and policy changes, and a greater emphasis on prevention – including blood pressure control, diabetes care, and other strategies for end-stage kidney disease – are needed in all populations and subgroups.

Half of the survey participants were doctors (attending physicians, fellows or interns), including internists, nephrologists, emergency physicians, intensive care physicians and palliative care physicians. Most of the other respondents were medical-surgical nurses. The average age of all survey participants was 39 years. Almost two thirds of the respondents were female.

“Providing inferior care in the form of emergency dialysis for patients with chronic kidney disease has a profound impact on the well-being of providers,” said lead study author Dr. Areeba Jawed who attended IU. Faculty of Medicine trained in internal medicine, nephrology, palliative medicine and clinical ethics. “We have to talk about these ethically challenging topics together in order to prevent moral injuries and burnout among the providers.”


Add moral stress to the long list of reasons for clinician burnout in healthcare today. Burnout, disengagement and the resulting staff shortage were named in a March survey as the most potentially disruptive forces hospitals and healthcare systems will face over the next three years.

The pandemic claims the psychological and emotional well-being of doctors, with doctors in intensive care and infectious diseases reporting the highest burnout rates during public health emergencies, according to a December burnout report from doctors at Medscape.

Burnout and the stress of the pandemic – including factors such as personal risk, social distancing and financial insecurity – seemed to reduce doctors’ overall satisfaction with work, with only 49% saying they were happy in 2020, up from 69% before the pandemic . More than a third (34%) said they felt unhappy in the past year, compared to 19% in 2019.

Twitter: @JELagasse
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