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Listening to patients who can't hear

Pick up tips to treat deaf and hard-of-hearing patients.

Deaf and hard-of-hearing patients not only have trouble hearing, they have trouble being heard, especially in the fast-paced hospital setting.

“Everybody that's involved in the field can probably tell stories about patients who weren't offered adequate communication access (say, through interpretation), and lack of adequate communication can have dangerous implications,” said ACP Member David A. Ebert, MD, a semiretired internist in Chicago who has worked with deaf patients for many years.

He recalled one young patient who was deaf, had gout, and would occasionally come in with painful attacks. One time, after a weekend ED visit, the man came to see Dr. Ebert with a splint on his foot. “Apparently they didn't have interpretation there, and they couldn't see a fracture on the X-ray, but they thought, ‘Well, this hurts so much, it may be broken,’” he said. “So they put a half-cast on him, which is not what he needed for his gout. He needed his gout medication.”

Deaf patients are relatively frequent visitors to the ED. Compared to the general hearing population, deaf American Sign Language (ASL) users had a 97% greater likelihood of having been to an ED over the past three years, according to a study published in the October 2015 Disability and Health Journal. They were also more likely to be repeat users of the ED.

Even partial loss of hearing is associated with increased hospital utilization. Disabling hearing loss affects about 25% of U.S. adults ages 65 to 74 years and 50% of those ages 75 years and older, according to the National Institute on Deafness and Other Communication Disorders. Older adults with hearing difficulties have a greater incidence and annual rate of hospitalization than those who do not have trouble hearing, according to a study in the June 2015 Journal of the American Geriatrics Society.

Hearing loss may even lead to readmissions, according to a research letter published in the November 2018 Journal of the American Geriatrics Society. In the survey, nearly 12% of about 4,500 older adults hospitalized between 2010 and 2013 said their hearing difficulties were severe enough that they had trouble communicating with their physician or other medical staff. Those who reported trouble communicating had, on average, 32% greater odds of 30-day readmission than those who did not.

“This is obviously big dollars, and we're not doing a good job at managing these populations,” said Michael McKee, MD, MPH, a researcher and assistant professor of family medicine at the University of Michigan in Ann Arbor. “A lot of it boils down to the ability to communicate effectively.”

That may sound challenging, but hospitalists don't have to learn ASL to effectively communicate with deaf patients. They also shouldn't shout to get through to patients with hearing loss, experts said. Instead, asking one simple question (Do you have a hearing loss?) can help physicians be more aware of patients' communication needs. This awareness can result in learning more about patients' preferences and technologies that may help them communicate more easily in the hospital.

Avoiding assumptions

People who have hearing difficulties fall into three main categories: Deaf, deaf, and hard of hearing. “Big-D Deaf generally suggests that the individual has looked at hearing loss as a cultural identification rather than a disability,” said Dr. McKee, who is a Deaf physician and fluent in ASL, which Deaf people in the U.S. generally use as their preferred language, rather than English. In contrast, individuals who identify as deaf often have a severe-to-profound hearing disability, but they generally do not sign, Dr. McKee said. Then there are the hard of hearing, who incorporate spoken English and may or may not lip read or use hearing-amplification devices, he said.

For all three categories of patients, the main challenges are navigation through the health care system, communication barriers, and discharge planning gaps, Dr. McKee said. The intense hospital environment also contributes additional stress, potentially worsening the above issues, he said.

Hospitals have a legal obligation to provide effective communication to the extent they are able, so part of a hospitalist's job is to figure out patients' preferences and try to accommodate them, noted Jan Blustein, MD, PhD, a researcher and professor of health policy and medicine at the Wagner Graduate School of Public Service at New York University in New York City. “Now that a lot of the baby boomers are having hearing loss, I predict that there will be a much greater awareness of this because baby boomers are so outspoken. . . . It's a matter of time before people begin to demand it,” she said.

The best way to communicate with a patient with hearing difficulties depends on the background of the individual, so making assumptions is not helpful, Dr. McKee said. “We generally do a poor job of assuming what the patients need in terms of communication preference and accommodations,” he said. “Instead of assuming, the first question is, ‘How can we effectively communicate with you?’”

D/deaf and hard-of-hearing patients may give a range of responses, including ASL interpreting, written communication, and lip reading. “The best communication strategy is that which works best for the patient,” said hospitalist Christopher Moreland, MD, MPH, FACP, associate clinical professor and associate program director of the internal medicine residency at UT Health San Antonio. In Texas and other areas of the U.S., patients may even use other spoken or signed languages like Spanish or Mexican Sign Language, which might call for qualified trilingual interpreters, he said.

Interpreters should be certified, either by a national (e.g., Registry of Interpreters for the Deaf) or state (e.g., Texas' Board for Evaluation of Interpreters) organization, and when they are needed, hospital staff should engage one as early as possible, Dr. Moreland said. “Too often people use untrained interpreters like family members, which can lead to serious miscommunications and errors of clinical consequence,” he said.

Physicians might assume that writing back and forth is the most effective method of communicating with D/deaf patients, but this can be a problem because not all D/deaf people are proficient in written English, Dr. Ebert said. “If you've got a D/deaf patient that uses sign language, don't make the mistake to think that writing back and forth is going to be satisfactory,” he noted.

Deaf ASL users generally have lower English reading literacy than the clinicians and staff who would be writing to them in a note, said Dr. McKee, who discourages lengthy note writing with D/deaf patients. “It's very slow, our writing is not legible, and we often use a lot of jargon, so it's a very ineffective tool,” he said, although he noted that writing may be useful for brief messages.

With this in mind, any written information (such as posted signs, consent forms, and Medicare information sheets) cannot automatically be considered effective communication, said Dr. Moreland, who is Deaf. He recalled one patient whose primary language was ASL, not written English, and who was not comfortable reading the instructions on her prescription medication bottle. To address the issue, Dr. Moreland wrote and rewrote parts of the prescription and asked her to read them back until it made sense to her. “The two of us kind of changed the language on that prescription in a way that made sense to us both,” Dr. Moreland said. “I think that negotiation process is a really nice example of how we should be communicating effectively in health care.”

Sometimes, clinicians think that patients with hearing loss have dementia because they respond inappropriately to speech, said Dr. Blustein. “A hospitalist who's thinking somebody's ‘out of it’ might want to consider the possibility that the person is not able to hear them,” she said.

Such patients, who may have acquired severe hearing loss or deafness as adults, often do not know ASL, Dr. Blustein noted. “Their primary language is going to be English, so giving them an ASL interpreter gets them nowhere. . . . That's one of the things that makes it hard for clinicians: It's not a one-size-fits-all approach,” she said.

For people with hearing loss who don't sign, lip reading can be a useful communication strategy, Dr. Blustein said. “Another thing hospitalists can do is face the patient when they talk to them. Sometimes they're charting or even have got a computer in front of them,” she said. “If they can allow the person they're talking to see their lips as they speak, that's really helpful.” (See sidebar for more tips on communicating with patients who have hearing loss.)

However, lip reading is limited as a communication strategy, especially for people who are profoundly Deaf and prefer ASL, Dr. Ebert noted. “Most people can only lip read about 20% to 30% of words, even when experienced with lip reading,” he said. That being said, lip reading can be part of an overall communication strategy in combination with other interventions, such as sound amplification products, said Dr. Ebert.

New possibilities

Modern technological advancements make it easier for D/deaf and hard-of-hearing people to have more independence and potentially to communicate with clinicians.

“Video relay service was a huge game-changer for us,” said Dr. Moreland, who was interviewed for this article through a video relay service app on his computer tablet. The phone-based system, which he uses most days, allows him to directly connect via video to an ASL interpreter, who interprets to a third party in real time in English. The service, which is publicly funded, is limited by the Federal Communications Commission to communication between individuals in two separate locations and, therefore, not used to facilitate communication on the wards.

In contrast, video remote interpreting services can provide ASL interpreting in the hospital. These services, which also support many spoken languages, connect D/deaf or hard-of-hearing patients with hearing staff in the same location by using an internet-based connection with a remote interpreter. This is useful when in-person interpreters are not available, such as during the first few minutes of an emergency or in remote locations, Dr. Moreland said.

At times, video remote interpreting services can be ineffective for various reasons, such as poor internet connections or critical illnesses that interfere with video-based understanding, Dr. Moreland said. “Video remote interpreting services have their limits. Care providers need to understand those limits and effectively engage in-person interpretation services where possible,” he said.

These issues come up often enough that many D/deaf people refuse to use video remote interpreting, but these services can be useful in specific situations, said Dr. McKee. For example, in some areas across the country, the process of attaining a medically certified sign language interpreter may end up delaying health care for hours, he said. “And in some situations, D/deaf individuals may have a very private health complaint and may not feel comfortable using a local community interpreter that might know them,” Dr. McKee said.

For communicating with patients with mild-to-moderate hearing loss, some experts have proposed equipping hospitalized patients with personal sound amplification products. “That's one strategy because roughly only about 20% of individuals with hearing loss have hearing aids,” said Dr. McKee.

The typical time between somebody beginning to have hearing loss and getting a hearing aid is purported to be 10 years, Dr. Blustein said, adding that hearing aids are expensive and that people don't like to admit they have hearing loss.

“The personal sound amplification products are relatively cheap,” said Dr. McKee. “They're probably anywhere from $50 to $100, so even could be considered disposable.” In contrast, hearing aids are currently about $3,000 each, and usually people need two, said Dr. Blustein. (However, in 2017, Congress passed a law allowing hearing aids to be sold over-the-counter, which should make them much cheaper.)

Most hospital stock rooms have pocket amplifiers, which are basically microphones attached to amplifiers that plug into people's ears, but before they can be used, either a nurse or doctor needs to write an order, Dr. Blustein noted. “Those things are incredible. Somebody who can't hear well, you watch their face after you put that on, and it's just fabulous. That's particularly useful if the hospitalist has to do something really important, like get informed consent,” she said.

Dr. McKee, who on single-person calls uses a Bluetooth phone clip that works directly with his cochlear implant to provide better audio quality, said future technology will be helpful for many D/deaf and hard-of-hearing individuals. In the next five to 10 years, there will likely be personal digital assistants or devices that provide computer-aided voice-to-text captioning, he said. Further in the future may be avatars that sign to users on their devices, acting as digital interpreters, Dr. McKee said.

Despite these advancements, it's important to remember that technology can fail and may not be useful for older people who aren't particularly tech-savvy, Dr. Blustein said. “There's a lot of high-tech stuff, but the thing I'm most excited about is the idea that maybe people will become aware. . . . If you slow down, face the person, give that person a break, and ask that person how they'd like to communicate, that goes a long way for a lot of people,” she said.