• Lilia Cervantes, Sara Richardson, Rajeev Raghavan, Nova Hou, Romana Hasnain-Wynia, Matthew K Wynia, Catherine Kleiner, Michel Chonchol, and Allison Tong.
• Denver Health and University of Colorado, Denver, Colorado (L.C.).
• Ann. Intern. Med. 2018 Jul 17; 169 (2): 78-86.

BackgroundIn 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.ObjectiveTo understand clinicians' experiences providing EOHD.DesignQualitative study using semistructured interviews.SettingA safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas.ParticipantsFifty interdisciplinary clinicians experienced in providing EOHD.MeasurementsInterviews were analyzed using thematic analysis. Outcomes included themes and subthemes.ResultsFour 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).LimitationWhether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences.ConclusionClinicians 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.Primary Funding SourceRobert Wood Johnson Foundation and Doris Duke Charitable Foundation.

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