Immigration enforcement in hospitals: a framework for health systems.

Hospitals are intended to be spaces of diagnosis, treatment, and healing, yet health systems are increasingly confronting immigration enforcement activity in and around clinical settings, including emergency departments, inpatient units, and other restricted care areas. These encounters may introduce fear, operational uncertainty, and ethical tension for patients, families, clinicians, and institutional leaders. In high-acuity environments such as trauma bays, perioperative areas, and emergency departments, the presence of enforcement personnel may be particularly disruptive to rapid clinical decision-making, patient trust, and the delivery of uninterrupted care. This perspective article proposes a practical, nonpartisan framework to guide health system responses to immigration enforcement encounters in clinical spaces. The framework is grounded in core legal and ethical obligations, including protection of patient confidentiality, compliance with the Health Insurance Portability and Accountability Act, adherence to the Emergency Medical Treatment and Labor Act, and maintenance of clinical boundaries between public and non-public hospital areas. We outline a three-phase approach: preparation before an encounter occurs, a stepwise real-time response, and post-event support for patients and staff. Key recommendations include establishing a clear written policy, designating a 24/7 legal or administrative point of contact, training frontline staff not to make legal determinations, aligning electronic health record practices to minimize unnecessary documentation of immigration status, preserving clinical care during enforcement encounters, and using structured debriefings after events. A trauma-informed approach is essential, recognizing that enforcement activity may reinforce fear, institutional mistrust, and prior experiences of violence or coercion. By standardizing protocols and centering patient care, hospitals can protect confidentiality, support clinicians, reduce operational confusion, and preserve their fundamental mission as places of healing without fear or favor.