High Moral Distress in Clinicians Involved in the Care of Undocumented Immigrants Needing Dialysis in the United States.
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SUBMITTER: Jawed A
PROVIDER: S-EPMC8309436 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionHealthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member.MethodsA scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies.ResultsA total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis.DiscussionThis scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.
| S-EPMC10832382 | biostudies-literature
Project description:We apply standard demographic principles of inflows and outflows to estimate the number of undocumented immigrants in the United States, using the best available data, including some that have only recently become available. Our analysis covers the years 1990 to 2016. We develop an estimate of the number of undocumented immigrants based on parameter values that tend to underestimate undocumented immigrant inflows and overstate outflows; we also show the probability distribution for the number of undocumented immigrants based on simulating our model over parameter value ranges. Our conservative estimate is 16.7 million for 2016, nearly fifty percent higher than the most prominent current estimate of 11.3 million, which is based on survey data and thus different sources and methods. The mean estimate based on our simulation analysis is 22.1 million, essentially double the current widely accepted estimate. Our model predicts a similar trajectory of growth in the number of undocumented immigrants over the years of our analysis, but at a higher level. While our analysis delivers different results, we note that it is based on many assumptions. The most critical of these concern border apprehension rates and voluntary emigration rates of undocumented immigrants in the U.S. These rates are uncertain, especially in the 1990's and early 2000's, which is when-both based on our modeling and the very different survey data approach-the number of undocumented immigrants increases most significantly. Our results, while based on a number of assumptions and uncertainties, could help frame debates about policies whose consequences depend on the number of undocumented immigrants in the United States.
| S-EPMC6150478 | biostudies-literature
Project description:BackgroundWhen working with surrogate decision-makers, physicians often encounter ethical challenges that may cause moral distress which can have negative consequences for physicians.ObjectiveTo determine frequency of and factors associated with physicians' moral distress caring for patients requiring a surrogate.DesignProspective survey.ParticipantsPhysicians (n = 154) caring for patients aged 65 years and older and their surrogate decision-makers (n = 362 patient/surrogate dyads). Patients were admitted to medicine or medical intensive care services, lacked decisional capacity and had an identified surrogate.Main measuresMoral distress thermometer.Key resultsPhysicians experienced moral distress in the care of 152 of 362 patients (42.0%). In analyses adjusted for physician, patient, and surrogate characteristics, physician/surrogate discordance in preferences for the plan of care was not significantly associated with moral distress. Physicians were more likely to experience moral distress when caring for older patients (1.06, 1.02-1.10), and facing a decision about life-sustaining treatment (3.58, 1.54-8.32). Physicians were less likely to experience moral distress when caring for patients residing in a nursing home (0.40, 0.23-0.69), patients who previously discussed care preferences (0.56, 0.35-0.90), and higher surrogate ratings of emotional support from clinicians (0.94, 0.89-0.99). Physicians' internal discordance when they prefer a more comfort-focused plan than the patient is receiving was associated with significantly higher moral distress (2.22, 1.33-3.70) after adjusting for patient, surrogate, and physician characteristics.ConclusionsPhysician moral distress occurs more frequently when the physician is male, the patient is older or requires decisions about life-sustaining treatments. These findings may help target interventions to support physicians. Prior discussions about patient wishes is associated with lower distress and may be a target for patient-centered interventions.
| S-EPMC7210358 | biostudies-literature
Project description:Importance:In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. Objective:To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. Design, Setting, and Participants:Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. Exposures:Enrollment in private health insurance coverage and scheduled dialysis. Main Outcomes and Measures:We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. Results:Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P < .001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P < .001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P = .007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P < .001). Conclusions and Relevance:In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.
| S-EPMC6439652 | biostudies-literature
Project description:Background and aimsEleven million unauthorized immigrants reside in the United States and may account for 3% of deceased organ donors. Recently introduced federal and state legislation propose to address access to organ transplantation among unauthorized immigrants. The national landscape of liver transplantation (LT) for unauthorized immigrants is unknown.Approach and resultsWe included all US LT recipients between March 2012 and December 2018 who were linked to Pew Center of Research data to estimate the population of unauthorized immigrants in each US state and by country of origin, based on US Census data. We categorized patients as unauthorized immigrants versus US citizens/residents. The main outcome measures were (1) the proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among total population in each US state and (2) graft failure and death post-LT. Of 43,192 LT recipients, 43,026 (99.6%) were US citizens/residents and 166 (0.4%) were unauthorized immigrants. Among unauthorized immigrants, most LTs were performed in California (47%) and New York (18%). The absolute difference in proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among the total population differed among states, ranging from +20% in California to -12% in Texas. The most common countries of birth among LT recipients who were unauthorized immigrants were Mexico (52%), Guatemala (7%), China (6%), El Salvador (5%), and India (5%). In competing risk analysis, unauthorized immigration status (vs. US citizens/residents) was associated with a similar risk of graft failure (subdistribution hazard ratio [sHR] 0.74; 95% confidence interval [CI], 0.40-1.34; P = 0.38) and death (sHR 0.68; 95% CI, 0.36-1.29; P = 0.23).ConclusionsLT for unauthorized immigrants is rare, and disparities in access to LT by state are present. Patient and graft survival among unauthorized immigrants is comparable with citizens/residents.
| S-EPMC7103423 | biostudies-literature
Project description:We make use of uniquely comprehensive arrest data from the Texas Department of Public Safety to compare the criminality of undocumented immigrants to legal immigrants and native-born US citizens between 2012 and 2018. We find that undocumented immigrants have substantially lower crime rates than native-born citizens and legal immigrants across a range of felony offenses. Relative to undocumented immigrants, US-born citizens are over 2 times more likely to be arrested for violent crimes, 2.5 times more likely to be arrested for drug crimes, and over 4 times more likely to be arrested for property crimes. In addition, the proportion of arrests involving undocumented immigrants in Texas was relatively stable or decreasing over this period. The differences between US-born citizens and undocumented immigrants are robust to using alternative estimates of the broader undocumented population, alternate classifications of those counted as "undocumented" at arrest and substituting misdemeanors or convictions as measures of crime.
| S-EPMC7768760 | biostudies-literature
Project description:Background:Several studies have highlighted the benefits of empathy in healthcare settings. A correlation between clinicians' empathy and patients' adherence and satisfaction, as well as the ability for the clinician to accurately assess family members' needs, has been found. However, empathy is often seen by clinicians as a risk factor for their wellbeing. This study aims to assess whether the level of empathy of clinicians working in critical care settings may expose them to moral distress, poor job satisfaction, and intention to quit their job. Methods:Italian clinicians who attended the 2016 "Smart Meeting Anesthesia Resuscitation in Intensive Care" completed the Empathy Quotient questionnaire, the Moral Distress Scale-Revised, and two questions assessing job satisfaction and intention to quit the job. Multiple linear and logistic regressions were performed to determine if clinicians' empathy influences moral distress, job satisfaction, and intention to quit. Age, gender, and profession were used as control variables. Results:Out of 927 questionnaires distributed, 216 were returned (23% response rate) and 210 were used in the analyses. Respondents were 56% physicians, 24% nurses, and 20% residents. Over half of the clinicians (58%) were female. Empathy resulted the only significant predictor of job satisfaction (? = 0.193; p < 0.05). None of the variables included in the model predicted moral distress. Conclusion:Empathy determined neither moral distress nor intention to quit. Findings suggest that empathy is not a risk factor for critical care clinicians in developing moral distress and the intention to quit their job. On the contrary, empathy was found to enhance clinicians' job satisfaction.
| S-EPMC6960200 | biostudies-literature
Project description:Prior research suggests social ties with undocumented immigrants among Latinxs may increase political engagement despite constraints undocumented social networks may introduce. We build on prior research and find across six surveys of Latinxs that social ties with undocumented immigrants are reliably associated with collective, identity expressive activities such as protesting, but not activities where immigration may not be immediately relevant, such as voting. Moreover, we assess a series of mechanisms to resolve the puzzle of heightened participation despite constraints. Consistent with prior research at the intersection of anti-immigrant threat and Social Identity Theory, we find Latinxs with strong ethnic identification are more likely to engage in political protest in the presence of social ties with undocumented immigrants, whereas weak identifiers disengage. We rule out alternative mechanisms that could link undocumented social ties with participation including political efficacy, a sense of injustice, linked fate, acculturation, outgroup perceptions of immigration status, partisan identity, conducive opportunity structures, and prosociality. Our contribution suggests the reason social ties with undocumented immigrants are not necessarily a hindrance to political engagement among Latinx immigrants and their co-ethnics is because they can draw from identitarian resources to overcome participatory constraints.
| S-EPMC11376481 | biostudies-literature
Project description:BACKGROUND AND OBJECTIVES:Veterans with ESKD initiate dialysis under the Veterans Health Administration (VHA), an integrated health system, or are outsourced to non-VHA providers. It is unknown whether outcomes differ according to their dialysis provider at initiation. We sought to evaluate the association between dialysis provider and mortality and hospitalization among United States veterans initiating dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Among 68,727 United States veterans who initiated dialysis in 2007-2014, we examined the association of dialysis provider (VHA versus non-VHA) at initiation with mortality and hospitalization rates in the first 12 months post-initiation. Associations were examined across adjusted models, accounting for demographics and comorbidities. RESULTS:Patients were 72±11 years, 5% were women, 24% were black, and 10% (n=7584) initiated at VHA dialysis centers. VHA dialysis center patients were younger, more likely to be black, had fewer cardiovascular comorbidities, and lower eGFR at dialysis initiation. VHA provider patients were more likely to be hospitalized in the first 12 months (adjusted incidence rate ratio, 1.10; 95% confidence interval, 1.07 to 1.14), but had lower all-cause mortality risk (adjusted hazard ratio, 0.87; 95% confidence interval, 0.83 to 0.93) in fully adjusted models. CONCLUSIONS:Veteran patients initiating dialysis with a VHA dialysis provider appear to have a lower mortality risk but higher hospitalization rates than veterans initiating dialysis at non-VHA dialysis units.
| S-EPMC6032569 | biostudies-literature
Project description:This study examines the prevalence of several types of hardship (e.g., bill paying and housing hardships) among immigrants by race and ethnicity in the United States using data from the 2008 and 2014 panels of the Survey of Income and Program Participation and logistic regressions. I find that Blacks, and to some extent Hispanics, are more likely to report hardships than Whites and Asians, who are about equally likely to report hardships. Exploring results by nativity and citizenship status, I find that immigrants who became U.S. citizens are less likely than the native-born population to report some kinds of hardship. Undocumented immigrants, however, are more likely to report some kinds of hardships, particularly in the 2008 panel conducted at the time of the Great Recession, which hit immigrants especially hard; this relationship, however, is explained by the lower incomes of undocumented immigrant households in the 2008 panel. Results within racial and ethnic groups are generally in the same direction but are less frequently statistically significant. Overall, these findings suggest that immigrants are not particularly prone to hardship, especially when other characteristics are controlled for. In fact, the lower likelihood of some hardships among foreign-born citizens suggests that they are positively selected: they may have unobserved characteristics that are protective, such as better health, stronger social networks, or money management skills. Because the foreign-born are less likely to be disadvantaged vis-à-vis the native-born when hardship rather than the official income poverty measure is used, this study highlights the importance of using multiple measures when assessing the well-being of immigrants.
| S-EPMC8932239 | biostudies-literature