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Communicating with Hard of Hearing Patients The needs of hard of hearing (HOH) patients are often overlooked by medical personnel. Arranging for a sign language interpreter for a deaf patient is fairly simple, but relatively few HOH patients know sign language. The type and severity of hearing loss will influence the success of encounters between HOH persons and medical personnel. A person with a mild hearing loss who wears an in-the-ear aid or a canal aid may require little or no special effort to communicate on the part of medical personnel. Communication with a person with a moderate to profound hearing loss may be more difficult, even if the HOH patient wears a behind-the-ear aid; especially those with a profound loss may have a great deal of difficulty understanding speech, even with a hearing aid, and some do not lip read as well as others. Remember, too, that only 35% of the speech sounds can be seen on the lips, so even the most proficient lip readers may miss some important information.

There are also differences in attitude/behavior among members of the HOH population. Those whose hearing loss is recent lack experience in handling it; they may seem bewildered, timid, or just nod or say "yes" to everything. Some will even deny the extent of their hearing loss. The medical person's goal is to make sure that HOH patients understand what their medical problem is, how it will be treated, and what they must do to make the treatment successful. If there are treatment alternatives, it is imperative that the patient understands these alternatives in order to make an informed choice.

Advance planning Communication always goes more smoothly if there is advance planning. At the time an appointment is made, the patient should be asked what accommodations can be made for hearing loss. Expect various responses; a person with a long-term hearing loss is likely to know exactly what is needed, while those who are new to hearing loss may not have an answer to this question. Do ask if the HOH person needs a sign language interpreter. Although most HOH people don't sign, some do and may be proficient enough to understand an interpreter. Some HOH patients will bring as assistive device, in addition to hearing aids, such as a Pocket Talker or a personal FM system. Providing such assistive listening devices may be helpful as many people are unaware of their existence and benefits. All personnel who will come in contact with the patient - receptionist, nurse, doctor, anesthesiologist, medical technician, etc. -should be made aware of the patients' hearing loss ahead of time.

The role of the receptionist The receptionist can set the tone for a HOH patient's office visit. The nurse in charge of the office or the doctor himself should instruct a new receptionist in how deal with HOH patients. Many patients will provide the receptionist with a sticker that can be put on the front of their records to remind the nurse and doctor that they are dealing with a HOH person and a list of communications tips that can be put inside the folder. If the patient does not, the receptionist should indicated on the folder in some way that the patient is HOH. The receptionist should be aware that the HOH patient is not likely to hear his or her name called, especially if it is called over a loudspeaker, and should assure the patient that someone will come out and get him or her when the doctor is ready. A notice on the intercom at the nurse's station can serve as a reminder. Or perhaps pagers that light up and vibrate could be substituted for the intercom. Again, most HOH patients will remind the receptionist of these things. The nurse in change of the office or the doctor himself should instruct a new receptionist in how to deal with the HOH patients.

During the office visit or medical procedure Get the person's attention first! Don't attempt to talk to patients while their back is turned or while they are looking at something else. Moving into the person's line of vision is the best way to do this.

Face the person and have the light on your face. Do not turn your face away or look down at papers in your hand while you talk to a HOH patient. Do not have patients sit where bright light shines in their eyes. In most offices, this situation can be remedied by closing the blinds or drapes, and the patient will most likely suggest this. If there is still a problem, exchange places with the patient, so that the light is on your face instead.

Speak up, but do not shout. Shouting only distorts what the person hears through a hearing aid. However, it is helpful to speak just a little louder than one usually speaks; this often lifts one's speech into a range that can be heard comfortably by the patient.

Speak slowly and clearly; don't overemphasize. Don't slow down too much; a conversational rate is best. Busy doctors who speak rapidly will have to work on this! Overemphasizing words often distorts them, and those who lip read do better if the sounds look natural on the lips .

Cut out as much background noise as possible. Unfortunately, most medical settings are quite noisy, and some of this cannot be helped. However, if there is noisy medical equipment that is not needed and can safely be turned off, do so. It is also helpful to eliminate as many interruptions as possible.

Don't hide your mouth with your hand or an object. And don't chew gum! If you wear a mustache that hides your upper lip, be aware that it will be almost impossible for the patient to speech read you, and you will have to repeat information often or write it down.

Rephrase rather than repeat a misunderstood sentence. Quite often, a patient understands what you have said except for one key word. If repeating the sentence does not result in comprehension, try saying it another way.

Write down important information to be sure it is understood. This is vital when giving instructions that must be followed carefully.

Have the patient repeat vital facts to be sure they are correct. This, in combination with written instructions, will give you some peace of mind in knowing that the patient understands and will follow your instructions.

In the hospital It is vitally important that "Hard of Hearing" be shown prominently on all medical records. A telephone with a visible alert, an amplified telephone, or a text telephone (TTY) should be arranged for the patient's room, as well as a TV with captions. Devices that light up when someone knocks should be attached to a HOH patient's door. Some kind of sign indicating that the patient is HOH should be displayed on the door of the patient's room and over the patient's bed. Consider keeping a few hearing aid batteries in the central supply area for patients who are admitted through the emergency room without an overnight bag.

Sometimes HOH people need to call the hospital to find out how a family member or friend is progressing or to talk to that person. They will use either a TTY or the telephone relay service to do so. Persons who answer a hospital telephone need to recognize the sound of a TTY and be prepared to answer with one and to understand how to use the relay.

Doctors and nurses should realize that the HOH patient is not likely to understand someone speaking through a surgical mask. Therefore, patients should be given instructions before medical personnel put their masks on, and masks should be removed if at all possible if further communication is necessary. Another option is to use clear surgical masks. When hearing aids must be removed during surgery, the patient should be told where they will be kept and when she/he will get them back. It is very important to reassure the patient that the aids will be kept safe! An arm or wrist band with pertinent information written on it, such as "hard of hearing, wears hearing aids, read lips" can be put on a patient following surgery to alert the recovery room nurse.

Patients' rights Remember that HOH patients have the same rights as any other patient. They include:
Full participation in their own health care
A conscientious effort by staff members to communicate to a patient his/her medical status and options
Courteous treatment from staff members
A reasonable response to their requests for help or service
Flexibility of staff members in using alternative communication procedures
Reasonable accommodation of their hearing loss, with assistive devices provided at no charge
Clarification of all bills and medical documents they are required to sign
Help in obtaining information concerning financial aid
Help in finding alternative ways of receiving follow-up care if the patient cannot use the telephone
The use of a hospital patient advocate, patient relations personnel, or a patient care coordinator for problem solving
The right to obtain more than one opinion about their medical condition

Nursing Home consideration Nursing home staff should regularly check hearing aids to see if batteries need to be changed and change the batteries for those residents who are unable to do it themselves. Staff should also be trained to recognize when a hearing aid needs repair and notify the patient's family. Some nursing homes have assistive devices such as Pocket Talkers available for patients to use in certain situations. No one except medical personnel should be allowed to clean a patient's ears with such things as Q-tips. Staff should watch for changes in behavior that could indicate a change in a resident's hearing. Modern hearing aids are so small that nursing home residents often lose or drop them This cannot be avoided entirely; however, staff should make every effort to see that the aids are kept in a safe place when not being worn. Nursing home officials should avoid placing a HOH resident near noisy places such as boiler rooms or laundry rooms. Besides interfering with a resident's ability to hear speech, loud noises are painful to many people who wear hearing aids. Piped-in music in dining halls also makes it hard for residents who wear hearing aids to carry on a conversation.

Other considerations Doctors and anesthesiologists must remember not to prescribe or administer ototoxic drugs. Some patients are not aware that some drugs can cause or exacerbate hearing loss and thus will not bring up the subject with a doctor. The doctor should review options and avoid prescribing ototoxic drugs, unless no alternative drug is available and the ototoxic drug is necessary for the patient's continued health.

One idea worth exploring is the use of mirrors, which could be strategically placed in the rooms where x-rays, scans, and other radiological procedures are done to enhance communication between the patient and the medical staff. Sometimes there may be several staff members in the room, and the HOH patient may understand little or none of what they say. Someone who must stand behind a patient during a procedure could gesture into a mirror to show the patient what she or he should do next (hold your breath, turn your head, etc.) .

When there is time to plan ahead, and when it is vital that the patient understand complex information, Computer Assisted Real Time (CART) captioning may be an option, particularly when the patient's speech reading and communication skills are especially low. In the CART process, a highly-trained captionist uses court reporting equipment connected to a computer with special software to record all spoken communication in stenographic shorthand. The software reinterprets the shorthand into readable English, which is displayed on the computer monitor and can be read by the HOH patient. Thus the patient receives all the information she or he needs during assessment and treatment sessions.

Family member may or may not be helpful A few HOH people like to take a family member along to ease communication in medical settings. Most, however, find that family members are not always helpful. Even a spouse is not likely to know the answer to some questions, such what kind of pain the patient is experiencing and how long she/he has had the pain, and the doctor-family member-patient interaction becomes a lot more complicated than the doctor-patient interaction. Even when the illness is serious and the news is bad, it is better to tell patient directly, as the family member, naturally enough, may try to make the situation sound better than it really is when explaining it to the HOH person later or even try to avoid telling the person at all. Even worse, a family member may attempt to make important treatment decisions for the patient without the patient's full knowledge of the situation.

Even when a family member is present, remember to look at and speak directly to the patient; do not refer to the patient in the third person. The family member should be there only to offer clarification on certain points. It is quite disconcerting to a HOH patient sit to the side while the doctor and family member carry on a conversation as if she or he weren't even there!

Finally . . . A HOH patient's experiences in medical settings are always more traumatic than those of a hearing person because of communication difficulties. The burden falls on the HOH person who may not be able to spare the energy or focus on remedies at a stressful time. Kindness and compassion on the part of the medical staff and the willingness to find and use some creative solutions can make a difficult situation more manageable for all involved.

By Melanie Magruder (Paula Esterle, Mary Lee Nelson, Agnes Miles, Tara Rowland, Lori Bishop, Hazel Tucker, Suzanne Blake, and Louise Wisdom contributed to this article.)

Resources for hospitals and other medical service providers

Staying in Touch! by Samuel Trychin, Ph.D., and Janet Albright, M.S. 92 pages, 1993. Nuts-and-bolts workbook with information and exercises aimed at helping hard of hearing people resolve communication problems.

Communication Access for Persons with Hearing Loss: Compliance with the ADA
Edited by Mark Ross, Ph.D. -- York Press, Inc., soft cover, 1994. Covers assistive devices and other technologies.

Communication Issues Related to Hearing Loss
by Samuel Trychin, Ph.D. 70 pages, 1993. An overview of causes and effects of hearing loss on those who experience it -- both people with hearing loss and their families. Helpful also to professionals who provide services to people with hearing loss.

The HLA (formerly SHHH) Hospital Program has been elected to the Associations Advance America Award Program, sponsored by ASAE, for its significant contribution in the areas of education and community service.
SHHH Hospital Program
Complete guide for hospitals to provide services for persons with hearing loss in health care settings and comply with the Americans with Disabilities Act (ADA).
Includes guidebook (People with Hearing Loss and Health Care Facilities), one staff training video (I Only Hear You When I See Your Face), one Patient with Hearing Loss brochure, 10 Tips for Communication cards, one set of two Tips for Staff posters, and stickers of the International Symbol of Access for Hearing Loss (50 1" x 1" stickers and five 5-1/2" x 7" stickers).
Complete Hospital Program Components may be purchased separately. (See below.)

People with Hearing Loss and Health Care Facilities: A Guide for Hospitals to Comply with the Americans with Disabilities Act
-- HLA (formerly SHHH) Publications, rev.1993 Includes staff training, ADA regulations, case studies and resources.

I Only Hear You When I See Your Face: Tips for Medical Personnel
-- Videotape produced by Hope for Hearing Research Foundation, UCLA, open-captioned, 10 minutes.
Demonstrates simple rules for communicating with patients with hearing loss.

Tips for Staff Posters Set of two posters for hospitals and long-term care residences. Titled "Communicating with Hearing Impaired People" and "Helping with Hearing Aids."

Tips For Communicating with Hearing Impaired People

1. Face the person you are speaking to.
2. Speak clearly and distinctly.
3. Do not shout.
4. Rephrase rather than repeat.
5. Do not cover your moth, chew, smoke or turn away.
6. Be patient.
7. Write your message, if necessary.

(Above tips, curtesy of Hearing Loss Association of America.)

Note for hospitals . . . Sometimes we need to call INTO a hospital to find out how a friend or relative is progressing, or to talk to that person. To do so we may use either a TTY or the relay. The people who answer a hospital phone need to recognize the sound of a TTY and be prepared to answer with one, and also be knowlegeable about the use of relay systems. Some hospitals set up a direct line for a deaf/HOH patient who is in for a long stay. It can be very frustrating to be on the outside and not be able to get a hospital to answer a TTY call, or worse yet, to hang up on the relay!