Healthcare today is steeped in financial, practical, and ethical nuances that must be considered by the practitioner. As leaders in healthcare, we must be proficient at not only delivering care, but also improving methods for others to deliver care. Through influencing legislation, researching best outcomes, or simply raising awareness this goal can be met. Recently an opportunity arose to research the topic of providing dialysis to undocumented immigrants (UI) within the United States. The findings are worth further discussion; withholding chronic care is ethically questionable, yet the management of limited resources necessarily defines who will and will not receive treatment.

A pathway of federal and state legislation has created the scenario of inconsistent dialysis treatment among the UI population. Starting in 1972, those with end stage renal disease (ESRD) were covered by Medicare to receive dialysis. Additional legislation in the 80’s, 90’s, and 2000s placed some limitation on care to UIs, requirements for emergency treatment, and special reimbursement plans for some hospitals. Today, whether a UI with ESRD is allowed to receive chronic dialysis care is decided at the state level and sometimes by the individual facility. Those UIs who do not receive chronic care are forced to visit emergency departments and be evaluated to determine if they are in a critical state requiring dialysis.

Although it may sound more fiscally reasonable to withhold dialysis until it is absolutely needed (thus reducing the number of times dialysis is actually delivered), this does not appear to be true. Sheikh-Hamad et al, determined that providing emergency only dialysis is 3.7 times more expensive than providing chronic dialysis.¹ Additional studies show that inpatient stays are greater (162 versus 10 days, p<0.0001), more blood transfusions (24.9 v 2.2, p<0.0001), with greater pain and lower level of function. Furthermore, inadequate dialysis can lead to pericardial effusion, nephrogenic ascites, and dialysis disequilibrium syndrome. ^2,3,4 Currently there are an estimated 5,500 UIs with ESRD.² In one study focusing on two New York hospitals, it was found that 58% of UIs receiving dialysis were Hispanic, all were poorly educated, had been in the US for five years before starting dialysis and 4% were aware of their condition prior to immigrating.⁵

Nurses have a particular conflict in practice. The American Nurses Association, Code of Ethics (Provision Six) states, “The nurse participates in … improving healthcare environments … conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.”⁶ When the Registered Nurse is caring for or making decisions in collaboration with the healthcare team to deny ESRD patients based on immigration status, the patient outcomes are worse, and possibly a mismanagement of limited resources. Although this problem will not be resolved at the individual practitioner level, there is enough evidence to warrant further scrutiny and possible change in practice.

Although a full exposition of the issue is beyond the scope of this article, the following alternatives to may warrant further research:

• Consider UI eligible for renal transplantation
• Contract with for-profit dialysis centers to provide care at a negotiated rate
• Place permanent catheters or fistulas
• Initiate peritoneal dialysis if feasible
• Standardize dialysis coverage for UIs at the federal level
• Grant special immigration status to UI dialysis patients
• Deport back to country of origin if adequate care and support can be identified

Some of these alternatives may be considered controversial. Placing a permanent treatment solution, such as a fistula, will not be compensated and is not considered an emergency intervention. Special immigration status already exists for other Humanitarian conditions under US immigration law.⁷ Professional organizations such as the American Nephrology Nurses Association, National Kidney Foundation, National Renal Administrators Association, and Renal Physicians Association, are encouraged to consider this topic from an ethical, practical, and financial perspective. Although the direct population impacted may be small, dialysis is a standard of care for these patients; well established through evidence based medicine, and can extend the quantity and quality of life. Additional analysis is required to determine the impact to community stakeholders, current infrastructure, and the possibility of encouraging additional illegal immigration for healthcare purposes.

References:

1. Sheikh-Hamad, D., Paiuk, E., Wright, A.J., Kleinman, C., Khosla, U., & Shandera, W.X. (2007). Care for immigrants with end-stage renal disease in Houston: a comparison of two practices. Texas Medicine, 103, 54-58.

2. Cambell, G., Sanoff S., & Rosner, M. (2010). Care of the undocumented immigrant in the United States with ESRD. American Journal of Kidney Diseases, 55, 181-191.

3. Raghavan, R. (2012). When access to chronic dialysis is limited: One center’s approach to emergent hemodialysis. Seminars in Dialysis, 25, 267-271.

4. Raghavan, R., & Nuila, R. (2011). Suriviors- Dialysis, immigration, and US law. The New England Journal of Medicine, 364, 2183-2185.

5. Coritsidis, G.N., Khamash, H., Ahmed, S.I., Attia, A.M., Rodriguez, P., Kiroycheva, M.K., & Ansari, N. (2004). The initiation of dialysis in undocumented aliens: the impact on a public hospital system. American Journal of Kidney Diseases, 43, 424-32.

6. American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD. Nursebooks.org.

7. U.S. Citizenship and Immigration Services, 2012.

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