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In Practice

Care for undocumented immigrants: Who is responsible?

Excerpted from the In Practice blog on

The May 31 issue of The New England Journal of Medicine contained articles about several important medical topics: a new treatment for septic shock, how long women should remain on drugs to prevent osteoporosis, the rescue and care of drowning victims. I won’t remember every detail of these articles — thank goodness computers make it so easy to look up information as I need it.

One article I know I’ll have no trouble recalling vividly and for a very long time, though, is a story, a case presentation of sorts, about an undocumented worker who wanted nothing more than to be sent home to die.


Cifuentes was 49 when he moved from Guatemala to California on a visa, hoping to earn enough money picking watermelons to pay for medical care for his daughter back home. She had been run over with a truck by a drug dealer. Cifuentes worked 60 hours a week on farms, as a painter, and then a landscaper, and was able to send enough money home to enable his daughter’s recovery.

Around the time his visa expired, though, Cifuentes himself became ill with metastatic cancer. He was referred for hospice care in Houston, where he last worked, but what he really wanted was to go home to Guatemala, reunite with his daughter, and die there. Who could, or should pay to transport him?

The author of this article, Dr. Ricardo Nuila, Cifuentes’s physician, petitioned the Guatemalan consulate to support Cifuentes’s final trip home. He argues in favor of physicians partnering with foreign consulates to provide undocumented immigrants with palliative medical care, especially at the end of life.

Nulla uses Cifuentes’s story to explore the dilemma of how — some would say “whether” — to meet the medical needs of undocumented immigrants. He points out that emergency funds through Medicaid are most often used for pregnant women and for children, but that adults with chronic diseases and those who are dying — such as Cifuentes — present a growing challenge. Often, they simply visit emergency rooms over and over, at great public expense and suffering greatly themselves, until they die.


Would it be more humane, and more cost effective, to transport dying immigrants home if they wished? Would this be an appropriate use of Medicaid funds? Would immigrants feel coerced to go home to die without further treatment, having no other alternative?

Immigration is one of many subjects about which people have strong and unshakable opinions. The fewer actual undocumented immigrants one knows, the easier it is to have firm views about them. Nulla has done both medical professionals and the public a service by using the traditional clinical case presentation to put a human face on a complicated political issue.

Dr. Suzanne Koven is a primary care
internist at Massachusetts General
Hospital. Read more from her blog at