Here’s a simple question that seems to confound many hearing health care professionals. What do you do with a patient who can’t hear anymore?
I guess we should back up a bit a define what we mean by “can’t hear anymore”. What I am referring to is patients with hearing losses typically in the profound hearing loss range with auditory-only monosyllabic word identification scores typically around 25% or less. Note that we need to look at both the hearing loss and the word identification score as the variability of communication performance in this hearing loss range is massive. Additional, we should look at auditory-visual word identification to see how well the patient can utilize the addition of lip-reading information.
Lets look at a case that I recently encountered. The woman had a left corner audiogram. Word identification score was 0%. Auditory visual speech perception was not much better, but was not assessed by the clinical audiologist with an AuD so we don’t really know.
I was contacted and asked if I could help with the FM fitting at this office. I agreed, but as is always the case, I was not given all the details. I got there, asked to see the file and my jaw dropped. The conversation with hearing health care professional (HHCP) went something like this:
Me: So what are we doing with this patient?
HHCP: We are fitting an FM system?
HHCP: What do you mean why?
Me: I mean “why?”, thats what I mean. What will the FM system do?
HHCP: It will help the client hear better. She and the family are pretty frustrated.
Me: Well of course they are. But how will the FM help the client hear better? Will it improve her word identification score?
HHCP: By improving the signal-to-noise ratio.
Me: When you did the word identification test, did you do it in background noise, or in quiet?
HHCP: In quiet.
Me: So we are already looking at the best possible score and thats 0%.
HHCP: I guess…
Note that this is not the first time I have had a conversation like this with an audiologist or a hearing instrument practitioner. It seems to me that most clinicians have no clue what to do with patients who have little or no hearing. I am not 100% sure of the reason for this, but I suspect that it goes back to our problems with our training. And that is as follows: We are only trained on how to assess hearing and how to fit a hearing aid.
The audiologist in this example is, like most of my colleagues, a good and decent human being who truly wants to help the patient, but doesn’t know how. He is simply the end product of his training.
As an audiologist who also had 0% word identification and little hearing, I would like to offer my hearing health care professional colleagues a few suggestions on what to do with these kinds of patients. This is just a starter list…books could probably be written on this topic.
1. Counsel the patient. Specifically, let them know that they cannot hear anymore and we need to change tactics. In the case example above, and with the managing audiologist’s permission, I sat down the patient and her family and told them just that. The woman’s son practically had tears in his eyes…tears of frustration. He said “You are finally the first person to finally tell us what we have been saying for years, “my mother can’t hear”.
2. Let them know what a hearing aid can realistically do. In this woman’s case, it might provide a few basic awareness cues of loud sounds in the environment. Thats it. It will do little for speech perception.
3. The patient has two basic choices now. 1. Cochlear Implants or 2. Switch entirely to a visual approach.
4. Cochlear Implants: Make the referral to the closest implant program. Give a basic description of what it does, but stress that you are NOT a cochlear implant audiologist and they should get the correct information from the proper professional. Resist the temptation to give too much information here, unless you are very informed about CI’s. And don’t worry about candidacy. Let the CI centre work that one out. Most audiologists wait way too long to refer to an implant centre. When in doubt, refer to the CI centre.
5. The second option is to switch to visual approach. This can include learning sign language, using written notes, using text messaging via a mobile phone, things of that nature.
6. Lip-reading as an exclusive method if communication is not an option in my opinion. An explanation why is another entire blog posting, but basically far too many words look the same on the lips and it is extremely exhausting to lip-read all day long. It is best used as a supplement to hearing. Works great for folks who still have some usable hearing. See a fellow blogger’s posting on this topic.
7. Discuss alerting devices that use visual or tactile stimulation. This folks need to know when there is someone at the door, if the phone rings, if there is a fire etc. Hearing Ear Dogs could be discussed here as well.
8. Give options for phone communication. In the past that would have meant getting a TTY (sometimes called TDD’s). Nowadays, we have even more options including text messaging, instant messaging, email via computers, email via smart-phones etc.
9. Make sure the patient knows about captioning. This includes TV, but also real-time captioning (CART).
I provided all this information to this lady and her family. I also took back the FM and told them that it would be a waste of money at this time, but if they got a cochlear implant, an FM system can be added then.
This woman, who’s hearing loss was progressive over the years, should have started using an FM system when her hearing loss was moderate-severe. Her time for the FM came and went. FM systems need to be added much earlier, not when the client is a CI candidate. That’s too late.