Lilia Cervantes, MD *; Sara Richardson, RN *; Rajeev Raghavan, MD; Nova Hou; Romana Hasnain-Wynia, PhD; Matthew K. Wynia, MD; Catherine Kleiner, PhD, RN; Michel Chonchol, MD; Allison Tong, PhD
Grant Support: This study was made possible by a Harold Amos Medical Faculty Development Award from the Robert Wood Johnson Foundation. The project was also supported by grant 2015212 from the Doris Duke Charitable Foundation and the University of Colorado School of Medicine.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0400.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available through written agreement with the authors (e-mail, firstname.lastname@example.org). Statistical code and data set: Not available.
Corresponding Author: Lilia Cervantes, MD, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204; e-mail, Lilia.Cervantes@dhha.org.
Current Author Addresses: Dr. Cervantes: Denver Health, 777 Bannock, MC 4000, Denver, CO 80204.
Ms. Richardson: Denver Health, 601 Broadway, 4th Floor, Denver, CO 80204.
Dr. Raghavan: Baylor College of Medicine Medical Center, 7200 Cambridge Street, 8th Floor, Houston, TX 77030.
Ms. Hou: University of Texas McGovern Medical School, 3011 Bell Street, Houston, TX 77003.
Dr. Hasnain-Wynia: Denver Health, 777 Bannock Street, MC 6551, Denver, CO 80204.
Dr. Wynia: University of Colorado, Anschutz Medical Campus, 13080 East 19th Avenue, Room 201 E, Mail Stop B 137, Aurora, CO 80045.
Dr. Kleiner: 3921 Lions Paw Street, Castle Rock, CO 80104.
Dr. Chonchol: Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, 12700 East 19th Avenue, Room 7015, Mail Stop C281, Aurora, CO 80045.
Dr. Tong: Centre for Kidney Research, The Children's Hospital at Westmead, Corner Hawkesbury and Hainsworth Street, Sydney, New South Wales 2145, Australia.
Author Contributions: Conception and design: L. Cervantes, S. Richardson, N. Hou, R. Hasnain-Wynia, C. Kleiner, A. Tong.
Analysis and interpretation of the data: L. Cervantes, S. Richardson, R. Raghavan, N. Hou, R. Hasnain-Wynia, M.K. Wynia, C. Kleiner, A. Tong.
Drafting of the article: L. Cervantes, S. Richardson, R. Raghavan, R. Hasnain-Wynia, M. Chonchol, A. Tong.
Critical revision of the article for important intellectual content: L. Cervantes, S. Richardson, N. Hou, R. Hasnain-Wynia, M.K. Wynia, C. Kleiner, M. Chonchol, A. Tong.
Final approval of the article: L. Cervantes, S. Richardson, R. Raghavan, N. Hou, R. Hasnain-Wynia, M.K. Wynia, C. Kleiner, M. Chonchol, A. Tong.
Provision of study materials or patients: L. Cervantes.
Statistical expertise: L. Cervantes, M. Chonchol.
Obtaining of funding: L. Cervantes.
Administrative, technical, or logistic support: L. Cervantes, S. Richardson, R. Raghavan, M. Chonchol, A. Tong.
Collection and assembly of data: L. Cervantes, S. Richardson, R. Raghavan, N. Hou.
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.
To understand clinicians' experiences providing EOHD.
Qualitative study using semistructured interviews.
A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas.
Fifty interdisciplinary clinicians experienced in providing EOHD.
Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes.
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).
Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences.
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.
Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.
Cervantes L, Richardson S, Raghavan R, et al. Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative Study. Ann Intern Med. 2018;169:78–86. [Epub ahead of print 22 May 2018]. doi: https://doi.org/10.7326/M18-0400
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Published: Ann Intern Med. 2018;169(2):78-86.
Published at www.annals.org on 22 May 2018
Nephrology, Renal Replacement Therapy.
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