What Do You Do When You Can’t Hear Anymore?

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?

Me: Why?

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: Sure.

Me:  How?

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.


10 thoughts on “What Do You Do When You Can’t Hear Anymore?

  1. The client was a CI candidate years ago, when their best aided speech discrim in quiet fell below 60%, with today’s relaxed guidelines. For more, please see this Hearing Review article, paying note to the orange area in the audiogram in Figure 2; and for the latest guidelines, see Who is a cochlear implant candidate? Figure 1 in this June 2011 article by Vanderbilt CI center director René H Gifford PhD in The Hearing Journal will surprise you.

    However, I strongly disagree with you when you write,

    Make the referral to the closest implant program.

    That may be what you have to suffer with in Canada because of healthcare rationing which has caused consolidation into regional CI centres (such as the absolutely awful Sunnybrook in Toronto); but here in the United States there are over 250 CI programs, and they vary widely in skill of the surgeon(s), and the quality of the audiologic follow-up. For example, the CI programs here in Philly are mostly abysmal, with the smart users driving 90 miles to Johns Hopkins in Baltimore or 80 miles to NYU & Manhattan Eye & Ear, where the surgeons implant all three brands in hundreds of people every year, have much better CI audiologists, and much better outcomes.

    Dan Schwartz,
    Editor, The Hearing Blog
    Follow The Hearing Blog on Facebook

    • Indeed she was. Thanks Dan, for this link. Although I do not agree with your statement about Sunnybrook, I do agree with the general gist of your comment.

  2. This is a very useful blog post. I am sure audiologists and doctors will come across it during brief websearches. I am glad you gave a real life example. My own hearing has been on a roller coaster. I am a very very good lipreader, but after a few months of relying on it, i realized how tired and frustrated and even angry I was about communication. My cochlear implant is slowly but surely bringing the world of sound back to me. Neither lip reading nor the implant alone is enough for me to carry on an extended conversation, but together they work well. The CI will improve over time.

    Anyhow,this is really great, what you did, just communicating the truth about the patient’s level of deafness and what the next steps need to be. You blog is tremendously useful and I am glad you post what you do.

    • Thanks for the comment Stephen. I do not know how long you have had your implant, but I personally needed over a year before I got full benefit. Like you, I still use lip-reading today to supplement what I hear. I hope you will continue to get improvements with your CI.

      • I am right at about 5 to 6 months. It has just been in the last few weeks that I have started to catch words out of the noise. Looking forward to more.

  3. Thanks for addressing this important topic, Peter.

    Thought I’d point out that in the United States, there are a variety of relay services for people with hearing loss that don’t require the use of a TTY. For example, people with hearing loss who can speak for themselves are able to use two different specialized phones that connect to the Internet and which allow them to use their own voices to talk with the other party while seeing relayed text (CapTel 800i and ClearCaptions), and which also allows them to receive incoming calls. Other CapTel phones also provide late deafened people the ability to use their own voice while received a relayed call.

    I don’t know what kind of relay services are available in Canada, but I would hope that at least Voice Carry Over (VCO) is available as that allows oral people with hearing loss and a compatible TTY to use their own voice to communicate for themselves. If VCO is available, then people should also be able to use 2-line Voice Carry Over (which allows them to hear the other person’s voice as much as possible). These services have been around since the 1990’s in the USA.

    • We have the same types of services Dana. But thanks for adding this relevant information. This topic of “what to do when you can’t hear anymore” could be a whole book.

  4. Nice article Peter! A pet peeve of mine is when a profound hearing aid user cannot tell if the hearing aid is working or not and have to rely on a battery tester to ensure battery still has juice. To me that’s a go figure!

  5. Might I also suggest pushing the envelop a little bit to include those with severe hearing losses and poor word recognition scores? Or no?

    • Of course you may. I was not trying to set some sort of cut off of who is “deaf” or “deafened”. Dan Schwartz’s link about CI criteria was excellent, take a look at that as well.

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