The limits of compassion: Dialysis and the undocumented – The problem

Editor’s note: This blog post is the first part of a two-part series.

Mr. H and I shared stories in his hospital room on a quiet morning, unaware that later that day I would be thrusting my palms onto his chest, manually beating his heart as our medical team resolved the electrolyte derangements that caused his heart to stop pumping blood to his brain and other organs.

Due to linguistic, financial, and legal barriers to care, Mr. H had poorly controlled type two diabetes mellitus that had been quietly destroying his kidneys for years. He came to the emergency center one day prior after weeks of fatigue, shortness of breath, fainting, and fluid-filled legs. His potassium, while elevated, was not high enough to warrant emergency action per hospital standard. The next day his heart gave out.

Though he was successfully resuscitated, the healthcare system failed him. Mr. H will again present to the emergency room in a precarious medical state, and hopefully we will bring him back from the edge.

I met Mr. J in the emergency center early in my internal medicine rotation. He was lethargic and had sunken cheeks, and with my stethoscope I could hear the inflammation irritating his heart.  At 21 years old, he had end-stage renal disease (ESRD), a chronic condition requiring artificial filtration of the blood.

Mr. J had been turned away three consecutive days and in a desperate attempt to obtain dialysis, he prepared himself a potassium-loaded banana milkshake. He received emergent dialysis after presenting with five times the normal blood urea nitrogen level (a measure of toxin excreted by our kidneys), inflammation around his heart, and potentially lethal potassium levels. An echocardiogram revealed that Mr. J’s heart pumped at only one-fifth the rate of a healthy heart, underscoring the gravity of his deteriorating condition.

Mr. H and Mr. J are two of the 6500 undocumented immigrants in the United States with dialysis-dependent ESRD. Although as third-year medical students we currently only have one year of clinical experience, we have heard this story time and time again.

The problem

If an individual’s kidneys cannot fulfill their central role of ridding the body of toxins, they become dependent on dialysis or require a kidney transplant to live.  For patients receiving hemodialysis (the most common form of dialysis in the U.S.), the standard of care is to give at least three treatments per week to remove toxins and fluids.

As in most states, undocumented immigrants with ESRD in Texas are ineligible for Medicare-funded, scheduled dialysis and rely instead on “compassionate” or emergent dialysis. These patients only receive dialysis when they present to the hospital in a life-threatening medical condition. By waiting for an emergency, dialysis is provided under the Emergency Medical Treatment and Active Labor Act (EMTALA), the Medicaid-funded loophole that mandates emergency care for all patients, regardless of citizenship status.

While emergent dialysis often corrects the immediate life-threatening condition, it does not sufficiently remove toxins and fluids from the body and contributes to progressive deterioration in patients’ health.

Not only does this practice lack compassion, it is staggeringly expensive. A study conducted at Baylor College of Medicine found the total cost of care for a year of scheduled dialysis was $77,000 compared to $280,000 for emergent dialysis due to emergency room visits, frequent hospital admissions, and prolonged stays.

Notably, the study does not account for the loss of labor associated with the hours patients waste in the emergency room waiting area only to be turned away if their condition is non-emergent. Due to irregular schedules, these patients often struggle to keep jobs.

A common misconception is that undocumented workers do not pay taxes and should be ineligible for medical coverage under public funds. However, undocumented workers contribute an estimated $11.64 billion annually in income, property, sales, or excise taxes. Furthermore, the Social Security Administration reported that undocumented immigrants contribute an estimated $15 billion annually to social security and only take out approximately $1 billion per year.

We are proud of the cultural and economic contributions of our immigrants. We cannot afford, morally or economically, to deny healthcare to undocumented immigrants when they need it most. In order to rectify this issue, there must be cooperation and action taken by local, state, and federal organizations and agencies.

-By Javier Santiago and Victoria Mitre, third-year medical students at Baylor College of Medicine

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