Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

Industry Insight

Ethical Challenge of Health Care for Undocumented Immigrants Yields Clinician Moral Distress

In one of the first studies to explore clinician moral distress related to the ethically challenging provision of health care to undocumented immigrants, researchers from Regenstrief Institute and Indiana University (IU) School of Medicine surveyed physicians and nurses to assess their perspectives on treating end-stage renal disease in undocumented immigrants, a condition 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 one-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. citizen patients.

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 thrice-weekly dialysis.

The most common factor contributing to moral distress in 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.

“The current health care system in the United States places health care providers individually and collectively in a difficult situation in which their ethical obligation to care for all patients cannot be fulfilled within the current system due to current health care finance policies,” the authors of “High Moral Distress in Clinicians Involved in the Care of Undocumented Immigrants Needing Dialysis in the United States” wrote in the peer-reviewed study published in the journal Health Equity.

“Health care for undocumented immigrants is a polarizing issue, but one we—patients, clinicians, and policy makers—must discuss,” says Regenstrief Institute Research Scientist and IU School of Medicine Professor of Medicine Alexia Torke, MD, MS, senior author of the new study. “The high level of moral distress over providing substandard care to undocumented individuals with end-stage kidney disease should be considered a sign that we are doing something wrong.

“We need 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.”

One-half of the study survey respondents were doctors (attending physicians, fellows, or residents) including internists, nephrologists (doctors who specialize in kidney disease), 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. 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. We must talk about these ethically challenging issues collectively to prevent moral injury and burnout in providers,” says study first author Areeba Jawed, MD, who trained in internal medicine, nephrology, palliative care, and clinical ethics at IU School of Medicine. At the time of the study, Jawed was an IU palliative care fellow and an assistant professor of internal medicine and a clinical ethicist at Wayne State University. She currently is an assistant professor at University of Michigan School of Medicine.

Authors of the study, in addition to Torke and Jawed, are Sharon M. Moe, MD; Melissa Anderson, MD; and James E. Slaven, MS, all of IU School of Medicine, as well as Lucia Wocial of IU School of Nursing and the Charles Warren Fairbanks Center for Medical Ethics IU Health, and Fahad Saeed, MB, BS, of the University of Rochester.

The authors conclude, “Emergent-only dialysis causes significant moral distress in clinicians. Legal and fiscal policies need to be balanced with the ethical and moral commitments of providers for ensuring standard of care to all.”

An estimated 4% of the U.S. population are undocumented immigrants. Approximately 6,500 of these individuals suffer from end-stage renal disease.

— Source: Regenstrief Institute


ATA Launches Initiative to Advance Role of Telehealth in Eliminating Health Disparities

Advisory Board of global health care leaders presents outline of strategic approaches to reduce disparities based on latest advances in telehealth services and technologies.

The American Telemedicine Association (ATA), the premier organization working to accelerate the adoption of telehealth, announces the launch and first phase of action in a new initiative to assess the applications of telehealth in addressing and eliminating health disparities in the United States. Led by a team of leaders in diverse health care areas including providers, payers, community health organizations, and policymakers, the new ATA CEO’s Advisory Group on Using Telehealth to Eliminate Disparities and Inequities has worked to outline a new framework for eliminating health disparities that will be the foundation of ongoing strategic analysis and a series of policy recommendations in the months ahead.

“In recent years, we have seen rapidly growing evidence that telehealth services can and should play a central role in strategies to address health disparities in the U.S. Our new ATA CEO’s Advisory Group brings together globally recognized leaders in health policy and service delivery who are uniquely positioned to outline the optimal strategies to use telehealth to address this very significant challenge,” says Ann Mond Johnson, CEO of the ATA. “With insights from a range of stakeholders, the Advisory Group has introduced a framework that identifies the essential components of a comprehensive plan that can make a positive difference for millions of patients and health care systems.”

Led by Kristi Henderson, DNP, NP-C, FAAN, CEO of MedExpress & Optum Virtual Care, and chair-elect of the ATA; Yasmine Winkler, director of GEHA Health and ATA board member; and Ron Wyatt, MD, MHA, vice president and patient safety officer of MCIC Vermont, the CEO’s Advisory Group on Using Telehealth to Eliminate Disparities and Inequities is working to outline a new roadmap to address inequalities in the delivery of health care information and services with a focus on both access and improving outcomes. With perspectives from stakeholders including care teams, community health leaders, policymakers, and telehealth service providers, the first phase of the strategy includes an overview of the components of a strategic plan to address disparities in the years ahead.

“We have a tremendous opportunity to create innovative ways to use telehealth to break down barriers to care,” Henderson says. “The insight that each leader is providing is essential to identify what those barriers are from connectivity to affordability and health literacy so that we can collectively make the health system more accessible to everyone.”

“As we have seen exponential growth in the applications of telehealth services in recent years, we also now have an historic opportunity to consider entirely new approaches to address these challenges more effectively than ever before,” Winkler adds.

“Over the next year, the Advisory Group will outline a series of steps designed to help the health care sector as well as patient communities and government leaders better understand and take direct action on opportunities to apply services in telehealth to a wide range of programs,” Wyatt says. “These efforts will be designed to improve convenience and fairness in access to care for millions of patients in the U.S. based on the framework outlined in the first stage of this effort.”

— Source: American Telemedicine Association