Case Presentation:
John Doe (J.D.) is a 61‐year‐old undocumented man of African descent with no previous medical care admitted to our institution with renal failure and acute onset of bilateral lower‐extremity weakness. He was diagnosed with end‐stage renal disease and started on hemodialysis (HD). Extensive workup of his weakness did not yield a definitive diagnosis. Three weeks after admission, he was ready for discharge but remained unable to walk or perform ADLs without assistance. Eight months later, he is clinically unchanged but remains in the hospital. Our standard measures to assist in discharge failed for many reasons. His immigration status makes him ineligible for federal or state benefits, financially precluding discharge to a nursing facility. J.D. could not furnish a passport or a list of family or friends that would assume responsibility for his care. Moreover, he is unwilling to go back To his home nation because HD is largely unavailable.
Discussion:
In a health care system where emergency rooms are a primary portal of entry and all patients are guaranteed care, undocumented patients are being admitted to hospitals in increasing numbers. As we discovered, the complexity of arranging a safe and appropriate discharge after admission is underestimated. Given the scarcity of precedence for this case, we assembled a multidisciplinary team that has met biweekly for 8 months and has yet to reach an acceptable solution. To illustrate the difficulty in This process, proposals from these sessions are analyzed using the 4 principles of medical ethics — respect for autonomy, nonmaleficence, beneficence, and justice. Only the ethical shortcomings are highlighted: (1) our institution provides J.D.'s care and living expenses indefinitely (justice — an inequitable distribution of hospital resources precluding our institution from caring for a patient truly in need of inpatient care); (2) with the assistance of The embassy. J.D. will be discharged to a community of his fellow countrymen in the United States (nonmaleficence — potential harm to J.D. as continuation of life‐sustaining treatment cannot be guaranteed; (3) provide a kidney transplant (justice, nonmaleficence — unfair distribution of a scarce donor organ; potential harm to J.D. if he is unable to obtain the necessary immunosuppressive Therapy); and (4) return J.D. to his home country providing all transportation costs (autonomy, beneficence, nonmalificence — J.D. does not wish to return home and doing so would almost certainly result in his death).
Conclusions:
The discharge of undocumented immigrants is complex. With little medical or legal precedence to provide guidance, physicians and administrators alike must make tough and often unsettling decisions. As illustrated, no solution is without shortcomings. However, by using a structured framework of analysis, such as the principles of bioethics, we can strive to make a decision that is as equitable as possible toward all those affected.
Author Disclosure:
A. Singh, none; S. Greenhalgh, none; A. Ansari, none; K. Parsi, none.