Caring for the Patient with Hearing loss

Content of today’s program Characteristics of the deaf and hard of hearing population Typology Signs and symptoms Emotional needs Funeral services and end of life customs Interventions Communication modifications Assistive technology Interpretive services

Content (continued) Resources Questions and Answers

Presenters Valerie Stafford-Mallis – MBA - Training/Education Programs Coordinator – Department of Health – Florida Coordinating Council for the Deaf and Hard of Hearing Donna Carlton – Executive Director – Community Center for the Deaf and Hard of Hearing

Learning Objectives Learn to recognize the 4 types of hearing loss Learn to recognize the physical & emotional manifestations of hearing loss Learn to select appropriate communication modifications Learn to select appropriate assistive technology Learn to select appropriate assistive services Learn to utilize community resources Apply knowledge to end of life care

Iatrogenic Causes of Hearing Loss Head and neck radiation Undiagnosed tumors and syphilis Ototoxic drugs Cisplatin (occurs virtually 100% of the time) Mustard, Vinblastine, Vincristine, Carboplatin, DCN Aminoglcoside antibiotics ( Gentamicin, Tobramycin, Neomycin) occurs 25% - 30% of the time NSAIDS Diuretics Quinine Derivatives What Is Ototoxicity? To many doctors, ototoxicity just means hearing loss or tinnitus. Others consider only drug side effects that affect the inner ear as being ototoxic. However, Stedman's Medical Dictionary11 defines ototoxicity as the "property of being injurious to the ear." Therefore, any side effect of a drug that damages our ears in any way is ototoxic whether it damages the outer, middle or inner ear. How Common Are Ototoxic Side Effects? How common are ototoxic side effects? The short answer is, "No one really knows." We apparently only see (and record) the tip of the iceberg. For extremely ototoxic drugs such as Cisplatin (used in the treatment of cancer), virtually everyone that takes this drug ends up with hearing loss. According to some researchers, not a single person escapes its ravages—100% of the people taking Cisplatin damage their ears.5 The resulting hearing loss "is usually irreversible (permanent)."8 Another very ototoxic class of drugs are the AMINOGLYCOSIDE antibiotics. Researchers estimate that between one and four million Americans receive AMINOGLYCOSIDE antibiotics (such as Gentamicin, Neomycin, Tobramycin) each year.7 According to one study, a person has a 25-30% chance of incurring hearing loss from taking any of the AMINOGLYCOSIDES.9 Another study pegs the figure at 63%.5 This means that between 250,000 and 1,200,000 people (and maybe as high as 2,520,000 people) in the USA incur hearing losses each year from taking just this one class of drugs. Add to these figures the untold numbers of people who experience other side effects from taking these same drugs—such as tinnitus, dizziness, vertigo and numerous other cochlear and vestibular (balance) problems—and you have a figure of alarming proportions. It is even more alarming when you realize we are just talking about a handful of ototoxic drugs in 2 of the more than 150 classes of ototoxic drugs!

Other Symptoms of Ototoxicity Tinnitus Distorted Hearing (hyperacusis) Auditory hallucinations Feelings of fullness Dizziness & vertigo Loss of balance Central auditory processing disorder Otitis media and otitis externa Ototoxic Drugs are Everywhere! There are at least 743 drugs that are known to be ototoxic.4 Here are just 84 of them. This gives an inkling of just how all-pervading ototoxic substances are in the medications we take without having a clue that these drugs may be harming our ears. ACE INHIBITORS such as Enalapril (Vasotec),2 Moexipril (Univasc), Ramipril (Altace) ACETIC ACIDS such as Diclofenac (Voltaren), Etodolac (Lodine), Indomethacin (Indocin), Ketorolac (Toradol) ALPHA BLOCKERS such as Doxazosin (Cardura) AMINOGLYCOSIDES such as Amikacin (Amikin), Gentamicin (Garamycin), Kanamycin (Kantrex), Neomycin (Neosporin), Netilmicin (Netromycin), Streptomycin, Tobramycin (Tobradex) ANGIOTENSIN-2-RECEPTOR ANTAGONISTS such as Eprosartan (Teveten), Irbesartan (Avapro) ANTI-ARRHYTHMIC DRUGS such as Flecainide (Tambocor), Propafenone (Rythmol), Quinidine (Cardioquin), Tocainide (Tonocard) ANTI-CANCER DRUGS such as Buserelin (Suprefact), Carboplatin (Paraplatin), Cisplatin (Platinol), Vinblastine (Velban), Vincristine (Oncovin) ANTI-CONVULSANT DRUGS such as Carbamazepine (Tegretol), Divalproex (Depakote), Gabapentin (Neurontin), Tiagabine (Gabitril), Valproic acid (Depakene) ANTI-MALARIAL DRUGS such as Chloroquine (Aralen), Mefloquine (Lariam), Quinine (Legatrin) ANTI-RETROVIRAL PROTEASE INHIBITORS such as Cidofovir (Vistide), Ganciclovir (Cytovene), Ritonavir (Norvir) BENZODIAZEPINES such as Diazepam (Valium), Estazolam (ProSom), Midazolam (Versed) BETA-BLOCKERS such as Atenolol (Tenormin), Betaxolol (Betoptic), Metoprolol (Lopressor) BICYCLIC ANTI-DEPRESSANTS such as Venlafaxine (Effexor) CALCIUM-CHANNEL-BLOCKERS such as Diltiazem (Cardizem), Nifedipine (Adalat), Nisoldipine (Sular) COX-2 INHIBITORS such as Celecoxib (Celebrex), Rofecoxib (Vioxx) H1-BLOCKERS such as Cetirizine (Zyrtec), Fexofenadine (Allegra) IMMUNOSUPPRESSANT DRUGS such as Cyclosporine (Neoral), Muromonab-CD3 (Orthoclone OKT3), Tacrolimus (Prograf) LOOP DIURETICS such as Ethacrynic acid (Edecrin), Furosemide (Lasix), Torsemide (Demadex) MACROLIDE ANTIBIOTICS such as Clarithromycin (Biaxin), Erythromycin (Eryc) OPIATE AGONIST DRUGS such as Codeine (Codeine Contin), Hydrocodone (Vicodin), Tramadol (Ultram) PROPIONIC ACIDS such as Flurbiprofen (Ansaid), Ibuprofen (Motrin), Naproxen (Anaprox) PROTON PUMP INHIBITORS such as Esomeprazole (Nexium), Lansoprazole (Prevacid), Rabeprazole (Aciphex) QUINOLONES such as Ciprofloxacin (Cipro), Ofloxacin (Floxin), Trovafloxacin (Trovan) SALICYLATES such as Aspirin, Mesalamine (Asacol), Olanzapine (Zyprexa) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) such as Fluoxetine (Prozac), Fluvoxamine (Luvox), Sertraline (Zoloft) SEROTONIN-RECEPTOR AGONISTS such as Almotriptan (Axert), Naratriptan (Amerge), Sumatriptan (Imitrex) THIAZIDES such as Bendroflumethiazide (Corzide), Indapamide (Lozol) TRICYCLIC ANTI-DEPRESSANTS such as Amitriptyline (Elavil), Clomipramine (Anafranil)

Physical & Emotional Considerations of Hearing loss

Recognizing Hearing Loss How to Recognize – Persons with Hearing Loss Straining or working harder to hear normal conversation Watching the face of a speaker closely to understand what's being said Often asking people to repeat themselves Misunderstanding what others are saying Turning the television or radio up so loud that the volume is bothersome Having ringing in the ears Wears one or two hearing aids Wears a cochlear implant processor in one or both ears May use a variety of assistive devices to augment hearing aids’ effectiveness Requires the speaker’s use of a microphone to amplify speech Do not understand public address announcements May not respond when spoken to if the proper visual cues have not been provided May respond to questions incorrectly because the question has not been understood May bluff when spoken to in order to avoid embarrassment of not hearing Has great difficulty hearing on telephones due to lack of visual cues May appear aggressive and hostile due to the frustration of struggling to hear May become passive and overly dependent on others to hear for them

Types of Hearing Loss Deaf Hard of Hearing Late Deafened Deaf-Blind

Degrees of Hearing Loss Mild Moderate Severe Profound When people lose their hearing they don't necessarily lose all their pitches equally. In fact, a common type of hearing loss is the ..ski-slope;'where low tones rJmaln intact, while high tones drop. There's also a reverse ski-slope, "cookie bite" and reverse cookie bite. Further, individuals also differ in speech comprehension. Two people with the exact same hearing thresholds may not hear exactly the same way. This can be hard for some to understand, but think about runners. All feet are different. Some people have flat feet, some don't, some people are bow-legged, some may have scar tissue from old injures, some legs are short, and others long. Many factors determine how fast you run and it is the same with hearing. Many factors determine how well you understand the words you hear besides just the measurements plotted on your audiogram. There are differences in how all your parts work together

The Speech Banana I like this picture with illustrations of where sounds fall on the audiogram. The speech banana is important to audiologists, since not understanding speech is what sends most people to the doctor. This banana illustrates the range of human voice and where some phonemes of the English language fall. It isn't perfectly accurate, of course, because all voices are different. However, you can see How the vowels and consonants of speech fall in different areas of the audiogram. 'M' and 'u' are usually nasally lower pitched sounds, while 'f and 's' are high-pitched sounds. Consonants and vowels that are clustered together will be difficult to discriminate if that area of hearing represented on the audiogram is lost.

Deaf Sense of hearing is non-functional without the use of technological assists May be congenital or acquired deaf vs. Deaf Deaf means a person whose sense of hearing is nonfunctional, without technology, for the purpose of communication and whose primary means of communication is visual. Unless otherwise specified, the use of the term “deaf” or “Deaf” also implies persons who are hard of hearing or deaf-blind. Note: There is a distinction between Deaf and deaf, with “Deaf” referring to those individuals who use American Sign Language and “deaf” referring to individuals who are deaf, but who may or may not use American Sign Language. Although this distinction is not reflected in this report, it is frequently reflected in the materials of grassroots organizations.

Hard of Hearing Can range from mild – moderate – severe – profound Can affect one or both ears Onset is usually gradual but can be rapid Hard of Hearing means a hearing loss which can range from mild to profound and can occur in one or both ears. It results in the possible dependence on visual methods to communicate in addition to use of residual hearing with or without the assistance of technology. People who consider themselves Hard of Hearing usually do not understand or use American Sign Language to communicate and do not identify themselves as deaf. Amplification of residual hearing is preferred and is achieved through use of hearing aids, cochlear implants, and use of a wide variety of assistive technology.

Late deafened Usually severe to profound Occurs after speech and language are fully formed Late-Deafened means a hearing loss that happens after the acquisition of speech and language and usually is moderate to profound in both ears. The acquisition and use of speech and language is key to the accommodations required. Late-deafness may occur suddenly or gradually over the years. There are many interchangeable characteristics between issues encountered by Hard of Hearing persons and Late-Deafened persons. The differences between the two populations are more semantic than actual.

Deaf-blind Substantial loss of hearing and vision May necessitate an SSP – Support Services Provider Does not have to mean total loss of hearing and vision It’s important to know the degree of residual vision and hearing to determine the appropriate type of visual, auditory, or tactile communications methods Deaf-Blind means a person who has a substantial loss of hearing and vision and who may utilize specialized visual, auditory or tactile communication methods.

Emotions Common to Loss of Hearing Grief Shock and Denial Anger Bargaining Depression Acceptance Emotional Issues – Common to Loss of Hearing Need to grieve the loss of their life as a hearing person Initial shock and denial Anger Bargaining Depression Acceptance Individuals with hearing loss often feel left out of mainstream life Hard of Hearing people may feel caught between the hearing world and the deaf world May not use or understand assistive technology and techniques such as sign language Feel a sense of isolation, detachment and are prone to depression Are either unemployed or underemployed due to lack of accommodations Are stigmatized by themselves and others Are often dismissed due to the difficulty of communication with them Often are viewed as “difficult” when they express frustration and anger

Hearing loss is linked to: irritability, negativism and anger fatigue, tension, stress and depression withdrawal from family and social situations social rejection and loneliness reduced alertness and increased risk to personal safety impaired memory and the ability to learn new tasks reduced task performance & independence diminished psychological and overall health Many people are aware that their hearing has deteriorated but are reluctant to seek help. Perhaps they don't want to admit they have a problem, are embarrassed by what they see as a weakness, or believe that they can "get by" without using a hearing aid. Unfortunately, too many wait years, before getting help. Untreated hearing loss has been linked to: irritability, negativism and anger fatigue, tension, stress and depression withdrawal from social situations social rejection and loneliness reduced alertness and increased risk to personal safety impaired memory and the ability to learn new tasks reduced earning and job performance diminished psychological and overall health There are negative social, psychological, cognitive and health effects of untreated hearing loss . . . with far-reaching implications that go well beyond hearing alone. In fact, those who have difficulty hearing can experience such distorted and incomplete communication that it seriously impacts their professional and personal lives, at times leading to isolation and withdrawal.

Effective communication with the deaf and hard of hearing patient Sensitivity Courtesy Common sense Shared responsibility between speaker & listener Don’t be afraid to ask Whatever works! Communication with a person who is deaf, hard of hearing, late-deafened or deaf-blind involves sensitivity, common sense and courtesy. Effective communication is a joint responsibility of the hearing person and the consumer who is deaf, hard of hearing, late-deafened or deaf-blind. Always feel free to ask, "What can I do to make it easier for the two of us to communicate?" There are many ways to communicate effectively--the situation determines the difference. Modified from "Deaf & Hearing People: Working Together," National Technical Institute for the Deaf Center, Center on Employment

Effective communication with the deaf and hard of hearing patient Attention Noisy background Light Be seen Obstacles Foreign objects Diction and speech Pace Volume Do get the person's attention before you speak. Avoid noisy background situations. Be sure that your face can be clearly seen: Do not put obstacles in front of your face. Do not have objects in your mouth such as gum, cigarettes, or food. Speak clearly and at a moderate pace. Be sure that light sources (windows and artificial lighting) are on your face and not behind your head. Use facial expressions and gestures that will help your listener to better understand. Give clues when changing the subject--it's easier for a person to lip/speech read you if he or she knows what the topic is. Let your listener know if and when the topic changes. Rephrase instead of repeating when you are not understood. Don't shout--shouting distorts speech and makes lip/speech reading more difficult. Talk TO a hard of hearing person, not ABOUT him or her. When in doubt, ASK the person with hearing loss for suggestions to improve communication. Be patient, positive, and relaxed. Modified from guidelines contained in Manual for Mental Health Professionals, Part II, Psycho-Social Challenges Faced by Hard of Hearing People, Samuel Trychin, Ph.D., published in 1991.

Effective communication with the deaf and hard of hearing patient Facial expressions and gestures Conversational transition cues Rephrase instead of repeating Talk TO a hard of hearing person, not ABOUT him or her. When in doubt, ASK Be patient, positive, and relaxed. Use facial expressions and gestures that will help your listener to better understand. Give clues when changing the subject Rephrase instead of repeating when you are not understood. Talk TO a hard of hearing person, not ABOUT him or her. When in doubt, ASK the person with hearing loss for suggestions to improve communication. Be patient, positive, and relaxed.

Guidelines for Communicating with a Person Who Uses Sign Language Get their attention first gentle tap on the shoulder, wave, flash lights, stomp on the floor hand slap a table. Use paper and pen while waiting for the Interpreter to show up Use open-ended questions to probe for understanding. Guidelines for Communicating with a Person Who Uses Sign Language To get the attention of a person who is deaf or hard of hearing, use a gentle tap on the shoulder, a wave, flashing lights, stomp on the floor or hand slap a table. While waiting for the Interpreter to show up, have a paper and pen ready for simple English questions that can be answered with a little more than a yes or no. Open-ended questions that solicit more than a yes or no answer will give you an idea of how much the deaf person understands. Do not attempt to get consent from the consumer who uses sign language until the interpreter is present. When asking a yes-or-no question, do not assume that when the consumer nods his/her head it is affirmation or understanding. Nodding of the head often means confirmation that the message is being received or is courtesy and nothing more. There are very specific signs that are used to indicate Yes or No.

Guidelines for Communicating with a Person Who Uses Sign Language Always use interpreter for informed consent When the interpreter is present, talk directly to the person who is deaf, not the interpreter. Don’t talk about the person in their presence Don’t say “Ask him/her” or “Tell him/her” Maintain eye contact. It is considered rude to carry on a conversation without maintaining eye contact. Guidelines for Communicating with a Person Who Uses Sign Language—Continued If you know basic sign language and finger spelling, use it for simple things. If you don't know, use natural gestures, mime and facial expressions (i.e., drink, eat). It is important to realize that the ability to interpret is much more than knowing how to fingerspell or sign. Even if you have taken one or more sign language classes, that does not mean you can replace the interpreter. Unless and until you have taken and passed the performance tests given through the Florida Registry of Interpreters for the Deaf (FRID) or the National Registry of Interpreters for the Deaf (RID), you are not qualified to interpret. When the interpreter is present, talk directly to the person who is deaf, not the interpreter. Do not use phrases such as, "Tell her..." or "Ask him...". Be courteous to the person during conversation. If the phone rings or someone knocks at the door, let the person know that you are responding to the phone or door. Maintaining eye contact with the consumer with hearing loss is vital when communicating. It is considered rude to carry on a conversation without maintaining eye contact. When you are speaking to a person through an interpreter, everything you say will be interpreted. It is the interpreter's job to communicate everything to the consumer

Guidelines for Communicating with a Person Who is Deaf-Blind Notify the agency/interpreter that the person is deaf-blind Advise agency which mode of communication is needed (visual sign language or tactile sign language). To walk with a deaf-blind person offer an elbow and your forearm. Guide - Never push or pull them along. Do not leave deaf-blind persons alone in an open space. Escort them to a safe place and let them know why you are doing this. Guidelines for Communicating with a Person who is Deaf-Blind If the person is hard of hearing and communicates in spoken language, use the same tips offered for communicating with people who are hard of hearing. Stay close so that the consumer who is deaf-blind can see the speaker's face. If the person is deaf and uses sign language, use the same tips offered for communicating with a person who is deaf person and uses sign language. Check to see if the person uses sign language close up or uses tactile (hand-over-hand) communication. When you call an agency or interpreter, notify the agency/interpreter that the person is deaf-blind and which mode of communication is needed (visual sign language or tactile sign language). When approaching or walking with deaf-blind persons, offer an elbow and your forearm and let them use it to guide them. Never push or pull them along. Do not leave deaf-blind persons alone in an open space. If you need to leave someone alone for a few minutes, escort them to a safe place (for example, a chair near the wall). Let them know why you are doing this. If using a paper and pen to communicate, use readable big print. If the person has Usher's syndrome or retinitis pigmentosa, make sure the lighting is good and without glare. Modified from ''Tips for Communication with a Deaf-Blind patient," Center for Health Care Access, League for the Hard of Hearing.

Types of Interpreters Sign language Interpreter Oral interpreter Multi-lingual interpreter Deaf-blind interpreter Video relay services Video remote interpreting CART _ Communication Access Real-time Translation Sign language interpreters – persons specially trained to facilitate communication between the deaf, hard of hearing and hearing persons. Professional sign language interpreters develop their skills and knowledge through extensive training over a long period of time. Simply knowing some sign language does not make one a qualified interpreter. Oral interpreters sit near the speech reader and repeat silently what is being spoken. They are trained to mouth the words distinctly and to supplement their meaning with expressions and gestures. A multi-lingual interpreter is skilled in spoken English, a foreign language, and the sign languages associated with them. A deaf-blind interpreter may use sign language at a close visual range or they may use tactile sign language, depending on the patient’s needs. Video Relay Services is regulated by the Federal Communications Commission. It requires three call participants: the deaf person, the hearing person, and the video relay interpreter. The VRS is provided free by the FCC, but the FCC prohibits calls between deaf and hearing callers in the same room. Thus, this should not be used in place of a medical interpreter in the healthcare setting. Video Remote Interpreting is a fee-based service provided by a variety of interpreting referral agencies throughout the country. This is useful in areas where it is difficult to provide a face-to-face interpreter in a timely manner. Hospice would enter into a contract with an interpreter referral agency for the provision of VRI services on an as-needed basis. The Hospice treatment team and the patient would be in one location and the interpreter, through the use of video cam and Internet technology, is in a remote location. CART is not really interpreting; it is actually more like court reporting stenography. Individual CART is a service provided for one deaf or hard of hearing patient. The CART provider sits near the patient, types the word for word translation of everything that is said, and the patient views the CART on a notebook-sized portable computer.

Finding Medical Interpreters Registry of Interpreters for the Deaf (RID) Local Deaf Service Center (Florida Deaf Service Center Association) Local Center for Independent Living (CIL

Finding Medical Interpreters Call Community Center Deaf and Hard of Hearing Registry of Interpreters for the Deaf website www.RID.org lists RID-certified interpreters by state along with their certifications See RID Standard Practice Paper – Interpreting in Healthcare Settings Florida Registry of Interpreters for the Deaf (FRID) www.fridcentral.com

Qualified vs. Certified Interpreters ADA mandates qualified interpreters Qualified interpreters Sign to the deaf individual(s) what is being said Voice to the hearing individual (s) what is being signed Accurately convey at least 95% what is being communicated Must be impartial Must maintain patient confidentiality Must facilitate effective communication

Family members are the worst interpreters They may be emotionally distraught They are seldom objective They may be unable to deliver difficult news Confidentiality is an issue Their use is not legally defensible in a court of law for all but the most extreme emergencies and even then, only until a qualified interpreter can be sought.

Telecommunications Devices And Services

Who Is FTRI? Florida Telecommunications Relay, Inc. Administrator of TASA Law (F.S. 427) A private not-for-profit organization NOT a state agency Governed by Board of Directors. Located in Tallahassee. Create awareness, educate public and promote the Florida Relay Service. Distribute specialized telephones to Florida residents.

FTRI EDP Amplified Telephones Clarity’s XL-40 (40 dB) VCPH … Volume Control Phone for the Hard of Hearing Makes incoming speech clearer. Includes a volume control adjustment. ClearSounds’ CSC-40 (40 dB) Krown’s Starplus (53 dB) Clarity’s W425 (30 dB)

FTRI EDP Specialized Equipment ILA … In-Line Amplifier (40 dB) Connects to a standard telephone. Increases the volume and makes incoming speech clearer. Provides more amplification. ClearSounds’ CS-IL40 Clarity’s HA-40

FTRI EDP Specialized Equipment VCO … Voice Carry-Over Telephone Allows a person to receive a text message through a relay service and verbally reply to the caller with his or her own voice. “read and talk phone”

CAP TEL CapTel User Other Party Captioning Service 1. You talk to the other party… 2. …who talks back to you to hear. 5. …for you to read on the CapTel display. Captioning Service 3. Everything they say also goes through a Captioning Service… 4. …who re-voices what is said to a powerful voice recognition system which transcribes the words into captions…

FTRI EDP Specialized Equipment TTY … Text Telephone Used to type a message to another TTY user or a person using a standard telephone through the Relay service. Built-in flasher that lights up when the phone rings. Ultratec’s 4400 Krown’s MP2000D Krown’s PP2000D

FTRI EDP Specialized Equipment VCPS … Volume Control Phone for the Speech Impaired (26 dB) Provides more volume for outgoing speech. Rings at 95 dB and amplifies incoming sound to 40dB.

FTRI EDP Specialized Equipment ARS … Audible Ring Signaler (95 dB) Plugs into a jack away from the telephone. Or connects directly to the telephone. Rings when the telephone rings and allows you to adjust tone and volume. Ultratec’s CrystalTone Clarity’s SR-200

FTRI Website www.ftri.org One destination for all information regarding the program User friendly and accessible to everyone

Assistive Listening Devices Pocket sized personal amplifiers TV Listening systems FM Systems Stethoscopes Loop Systems Various Accessories Pocket-sized personal amplifiers are portable and are great for one-on-one conversations and for TV listening. They are helpful in cars and in other situations where it is difficult to face someone who is speaking. Cost around $150. TV listening systems connect directly into a TV’s audio jack and use infrared (IR) and radio-frequency (RF) signals to travel to the receiver the listener wears as a headset or a lavaliere. Begin at $200 Personal FM systems use frequency modulation (FM) sound waves to eliminate background noise and are capable of transmitting the signal over greater distances than the RR and IR systems. They eliminate wires between transmitter and receiver as well. Begin at $900. Electronic stethoscopes provide sound amplification up to 18 times greater than the best non-electronic stethoscopes. Around $600 Loop technology consists of a thin wire loop that is placed around the listening area (such as an entire room of a building or the interior of a vehicle). Speech signals are amplified and circulated through the loop wire. The resulting magnetic energy field is picked up by the induction loop receiver, cochlear implant or the hearing aid’s t-coil switch. The highest quality of amplified reproduction of the original sound possible is produced. Environmental noises are dramatically reduced. A large area loop system is available for approximately $1000. Accessories: Bluetooth Hands Free Headsets ($125), Bluetooth Neck loops ($170) Silhouette Ear Hooks for cell phones ($40)

Assistive Devices & Services Alarm clocks Timers and watches Door signalers Phone/strobe signalers Paging systems Weather Alert systems Visual/auditory/tactile alerters

Assistive Device Demonstration Advocates for Better Hearing  4221 S. Tamiami Trail Sarasota FL 34231 1/2 mile south of Bee Ridge Rd. Hours 10 AM – 4 PM Monday – Friday (941) 922-1242

End of Life Services & Customs The Deaf community is a close knit community Legacy.com - They rely on email and texting Accessible memorial and funeral services ASL CART Voice interpreters Written personal life history of the deceased Hi Valerie I am not aware of any customs for funerals/wakes that are deaf specific. You are right about the accommodations needed at the funeral/wake. At the Bayou apt building, the deaf often would have their own memorial service and anyone who wanted would stand up and share memories of their deaf friend who passed away. I attended a few of those. I am not sure if I would say that is a custom. In these cases, the hearing family would do the wake/burial etc but the deaf would gather for their own memorial Deaf love to socialize and it is the deaf way to sit and talk and talk with other deaf and tell stories. This is not just at funerals/wakes... It's at all gatherings. If it is a hearing family member who has died, and communication was limited for the deaf family member throughout the growing up years, they can have very strong feelings. Another theme I encountered in counseling is the deaf patient often did not seek out medical help because of the lack of accommodations or lack of mone or when they did see a dr they were not understood (no interpreter). Then they end up in an emergency room learning they have a life threatening illness. Often they feel angry because if they had the proper accommodations at doctor appts they could have properly explained their symptoms and perhaps detected ahead of time the illness (cancer, etc) If I think of more I will write Lois Maroney, LMHC Sent from my Verizon Wireless BlackBerry

Thank you! Questions?