CI Atlas · Candidacy & Evaluation · Module 20

20The team decision

Every thread of the chapter now ties together into a single judgement. No one test, and no one clinician, decides candidacy; instead the audiological, medical, imaging, language, psychological and developmental assessments are assembled in tiers and brought to a team meeting, where their different perspectives are weighed. That structure exists because the decision is genuinely multidimensional — anatomy, motivation, expectations, support and the audiogram all bear on whether the implant will outperform the aid and be used to good effect. A careful team sometimes concludes that the answer is no, at least for now. When the answer is yes, candidacy hands the patient on to the surgery, the device choice and the programming that the rest of the atlas describes. This closing module is about making, and acting on, the decision.

FAssembling the judgement

Candidacy is the sum of everything in this chapter: the best-aided speech score, the outcome predictors, the medical and imaging findings, the psychosocial picture, and the ear-selection plan. The art is integrating them — no single result is decisive, and a strong showing on one axis can be offset by a concern on another.

No single test decides candidacy. The work-up runs in tiers — audiology and otology with imaging at the core, then language, auditory-skills and educational input, then ophthalmology and psychology, then any pre-implant training — and converges on a team meeting. Bringing different perspectives to bear is how a centre weighs not just the audiogram but motivation, support, anatomy and expectations, and arrives at a decision (sometimes a decision not to implant). It is the structure that turns all the previous modules into one judgement. Schematic, after Niparko.

TThe tiers and the team meeting

The work-up runs in tiers — audiology and otology with imaging at the core, then language, auditory-skills and educational input, then ophthalmology and psychology, then any pre-implant training — and converges on a multidisciplinary team meeting. Bringing different professionals together is how a centre weighs not just the audiogram but motivation, anatomy and expectations, and reaches a decision that no individual could make as well alone.[2009]

CWhen the answer is no

A candidacy assessment can, and sometimes should, conclude not to implant — a substantial share of referrals do. The reasons are usually not strict contraindications but better alternatives or poor prospects: more benefit achievable with revised hearing aids, an excessive duration of profound deafness predicting little gain, unmanaged general or mental-health issues, or unrealistic expectations that cannot be reshaped. True contraindications are few — chiefly an absent cochlear nerve or an ear that cannot be safely operated on. Saying no when no is right is part of good candidacy.

TFrom decision to surgery

When the decision is to proceed, candidacy hands the patient forward. The team's findings shape the surgery, the device and array choice, and the programmingplan — the subjects of the chapters ahead — and the patient enters the pathway of activation, follow-up and rehabilitation. The candidacy clinic has done its job when it has answered, with the whole team's judgement, the question this chapter opened with: will the implant beat the aid for this person — and are they ready for it?

TCWeighted scorecards and the ICF model

Some teams formalise the judgement with a weighted scorecard. The Children's Implant Profile (ChIP) rates eleven factors — age, duration of deafness, medical and radiological findings, secondary handicaps, functional hearing, speech-language, family support, expectations, education, support services and cognitive style. Its key rule is non-compensatory: any single factor rated a “great concern” should be remedied before surgery rather than averaged away by strengths elsewhere.

The multidisciplinary decision can be structured like the Children's Implant Profile (ChIP): rate each factor — duration of deafness, medical/radiological findings, secondary handicaps, family support, expectations, education — and combine them. The crucial rule is non-compensatory: any single factor rated a “great concern” should be remedied before surgery rather than averaged away by strengths elsewhere. The team also distinguishes capacity (what the patient could do in an ideal clinic) from real-world performance (the ICF model), and applies a fixed standardised test protocol to guard against bias — turning numeric gates, odds, imaging, vestibular and psychosocial findings into one go / remediate / no-go verdict. Schematic.

Underlying this is the biopsychosocial (ICF) view, which distinguishes capacity (what a patient can do in the ideal clinic) from real-world performance, and insists that selection weigh environment, motivation and family attitudes alongside the audiogram.[1995] A fixed, standardised test protocol applied identically to every candidate guards the whole process against examiner bias. The scorecard, the actuarial odds, the neural-reserve estimate, the imaging, vestibular and psychosocial findings then converge into one go / remediate-first / no-go verdict — judged against real-world function, not just the booth.

Case 12.20 · The team says no

At the multidisciplinary meeting, a referred adult is found to gain substantially more from a revised hearing-aid fitting than expected, with good aided speech. The team considers the decision.

What is the appropriate outcome?

Self-assessment — Module 202 questions

Question 1 · Foundation

How is the candidacy decision ultimately made?

Question 2 · Clinician

Is 'do not implant' a legitimate outcome of candidacy assessment?

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