Impact of Partner Bereavement on Quality of Cardiovascular Disease ManagementClinical Perspective
Background—Bereavement is a period of increased risk of cardiovascular death. There is limited understanding of the potential contribution of quality of cardiovascular disease management to this increased risk.
Methods and Results—In a UK primary-care database, 12 722 older individuals with preexisting cardiovascular disease (coronary heart disease, hypertension, diabetes mellitus, stroke) and a partner bereavement were matched with a non-bereaved control group (n=33 911). We examined key routine annual process measures of care in the year before and after bereavement and cardiovascular medication prescribing (lipid-lowering, antiplatelet, renin–angiotensin system drugs). Odds ratios for change after bereavement compared with the change in non-bereaved matched controls are presented. In the bereaved, uptake of all annual measures was lower in the year before bereavement, with improvement in the year after, whereas in the controls, uptake was relatively stable. The odds ratio for change was 1.30 (95% confidence interval, 1.15–1.46) for cholesterol measurement and 1.40 (95% confidence interval, 1.22–1.61) for blood pressure measurement. For all medication, there was a transient fall in prescribing in the peri-bereavement period lasting until about 3 months after bereavement. The odds ratio for at least 80% prescription coverage in the 30 days after bereavement was 0.80 (95% confidence interval, 0.73–0.88) for lipid-lowering medication and 0.82 (95% confidence interval, 0.74–0.91) for antiplatelet medication compared with the change in non-bereaved individuals.
Conclusions—Lower uptake of key cardiovascular care measures in the year before bereavement and reduced medication coverage after bereavement may contribute to increased cardiovascular risk. Clinicians need to ensure that quality of cardiovascular care is maintained in the pre- and post-bereavement periods.
The effects of bereavement on mortality are well documented and include an increased risk of death from cardiovascular causes in the years after bereavement.1–4 In addition, a very high risk of myocardial infarction in the days after bereavement has been described, consistent with evidence on acute psychological stressors as precipitants of acute cardiac events.5,6 There are a number of plausible physiological mechanisms for both short- and long-term increases in risk.7,8 Longer-term effects of bereavement on cardiovascular risk may be mediated by a range of factors, including changes in lifestyle, social support, and depression, as well as physiological responses. However, there has been limited investigation of the role of changes in medical and cardiovascular care around the time of bereavement.
Editorial see p 2725
Clinical Perspective on p 2753
People with preexisting cardiovascular disease are routinely offered secondary prevention through risk-factor management and prescription of medications, including statins, antiplatelet agents, and drugs acting on the renin–angiotensin system (RAS), that improve survival.9 It is plausible that changes to this care around the time of bereavement may modify the risk of cardiovascular events. In the short term, poor control of risk factors or reduced medication prescribing may exacerbate any adverse physiological responses to grief that act as precipitants for acute events, such as plaque rupture leading to myocardial infarction.7 In the long term, poor risk-factor management or low medication coverage will increase background cardiovascular risk.
In this study, we investigate the impact of partner bereavement on the quality of care for patients with preexisting cardiovascular disease. Specifically, we examine routine annual process measures of cardiovascular care and medication prescribing in the year before and after bereavement in a UK primary-care population.
The Health Improvement Network (THIN) is an established primary-care database that collects anonymized data from volunteer UK general practices. The data include a full record of diagnoses and prescribing and are representative of the UK population.10,11 A feature of the THIN database is the family number, which allows practices to identify patients who live in the same household.12
The National Health Service South-East Multicentre Research Ethical Committee approved the THIN scheme to collect anonymous patient data in 2002. This approval allows collection of anonymized patient data for research. This specific study was further approved by the South-East National Health Service Research Ethics Committee (11/H1102/3).
Of 495 practices providing data to the THIN scheme at study inception in 2010, we included all 401 practices active in the scheme between 2005 and 2008 that were able to provide data for at least 1 year. We used a historical patient file to identify the household composition for a cohort of older patients aged ≥60 years on a specified date between 2005 and 2008 for each practice (n=672 543).
We based our approach to identification of cohabiting couples on an analysis of national survey data. This showed, among those aged ≥60 years, that couples of the opposite sex living together in a household with <10 years age difference are almost invariably (94.4%) married or cohabiting.13 We developed an algorithm that identified households that contained an older person aged ≥60 years living with another adult aged ≥50 years of the opposite sex. We required included couples to have an age difference of ≤10 years and that no younger adult in the household be within 15 years of either of the couple. This approach identified 171 720 eligible couples.
Couples were followed in the primary-care record from the specified date for their practice to their last practice data collection date up to September 2011. The timing of bereavement was identified through the record of death in the deceased partner’s primary-care record. The recording of date of death in the THIN database has been validated, with ~95% within 1 day of the actual date when recorded via a Read code on the medical record.14 The small proportion of deaths (~9% in our couples) that are ascertained through de-registration flags tend to be given a date a few weeks later than the actual date of death. A total of 31 370 older people (18% of couples) experienced bereavement during follow-up.
From the 31 370 bereavements, we identified subjects who had a diagnosis of coronary heart disease, stroke, diabetes mellitus, or hypertension at least 1 year before bereavement and were aged 60 to 89 years at baseline. This identified 14 621 individuals with partner bereavements and at least 1 year of potential follow-up.
Identification of disease diagnoses was based on a record of Quality and Outcome Framework (QOF) Read codes for these conditions in the primary-care record. QOF is a national pay-for-performance primary-care incentive system in the United Kingdom that defines nationally agreed disease codes and standards of care for chronic conditions.15
For comparison, we identified, from the couples, an age (in 5-year age bands)-, sex-, and practice-matched control group of non-bereaved individuals with the same eligible preexisting conditions who were registered on the date of bereavement (index) date of their matched set. We did not exclude controls who became bereaved after the index date because this would potentially lead to a biased comparison group who were not at risk of bereavement themselves. Up to three non-bereaved controls were identified for each bereaved individual.
All included bereaved couples and controls were required to have at least 1 year of registration before the bereavement (index) date and at least 1-year follow-up after that date for inclusion in our main analysis.
Processes of Care
We identified the occurrence of key routine process measures of care or prescribing outcomes in the year before and after bereavement for eligible patient subgroups. These were based on quality indicators in QOF and the RAND Institute Assessing the Care of Vulnerable Elders project.15,16 Processes of care and eligible subgroups of patients are listed in Table 1. This includes a depression screening indicator that is derived from QOF. Patients with coronary heart disease or diabetes mellitus in the United Kingdom are screened annually for depression using standardized questions.
For prescribing of lipid-lowering medication, antiplatelet medication, and drugs acting on the RAS, we estimated daily medication coverage for each individual based on quantity prescribed, dosage instructions, and date of prescription, in the year before and after bereavement. For example, a 30-tablet once-a-day prescription of a statin is assumed to give 30 days of coverage from the date of prescription.
We also identified contact with primary care, in the year before and after bereavement. Contact was measured as contact days, which were defined as the number of days on which there was a record of contact with primary care excluding administrative events.17
Initial self-controlled analysis compared uptake of each process of care in the year before and after the index (bereavement) date for each individual to allow an estimate of the change in uptake within the bereaved and non-bereaved control group separately. Subsequent analysis compared the change in the bereaved individuals with their matched non-bereaved counterparts to estimate the effect of bereavement on uptake adjusted for any background temporal trends in the control group.18 Analyses presented are restricted to bereaved individuals with at least 1 matched control with a full year of follow-up.
Daily prescribing coverage is presented graphically and then summarized as the proportion of patients with at least 80% medication coverage in the 30 and 90 days after the bereavement (index) date. This is compared with a seasonally matched control period 1 calendar year earlier for each individual. The change in the bereaved group is then compared with non-bereaved controls.
Analyses were performed using conditional logistic regression (PROC LOGISTIC, SAS version 9.2). For comparisons within subject, the model was conditioned on the individual, and a term for period (pre or post index date) was used to compare outcomes in the year before and after the index (bereavement) date in bereaved and non-bereaved individuals separately. For comparisons between subjects, the model was instead conditioned on match-set grouping. First, a term for bereavement status (yes or no) was used to compare outcomes in the year before and after the index (bereavement) date separately. Then a combined model with an interaction term for period and bereavement status was used to compare the difference in change of outcomes between bereaved and non-bereaved individuals. The odds ratio for the interaction term is an estimate of the impact of bereavement adjusted for temporal trends in the non-bereaved group. An odds ratio >1 suggests that improvement in the bereaved group is greater than in the non-bereaved group.
Control for Confounders
Unadjusted odds ratios for comparison between bereaved and non-bereaved controls are presented. In addition, we adjusted comparisons for age, comorbidity (using the Charlson index), smoking status, and area deprivation score.19,20 These confounders were chosen based on our previous work, which has examined uptake of influenza vaccine and statins and identified these factors as predictors.21,22
Characteristics of Sample
The number and disease characteristics of eligible bereaved individuals and their matched controls are shown in Table 2. Across all eligible groups, 13 135 (89.8%) of bereaved individuals had at least 1-year follow-up, of which 12 722 (96.9%) had at least 1 matched control. For all eligible groups of bereaved individuals, >90% of subjects had at least 1 matched control. Bereaved individuals were on average 1 year older than their controls and more likely to be women as a result of the lower complete matching (3:1) rates for older bereaved men. Bereaved and control groups were very similar in terms of distribution of conditions and the proportion of patients who had a diagnosis of their cardiovascular condition at least 5 years before the bereavement (index) date (Table I in the online-only Data Supplement). During follow-up, 1217 (3.6%) of non-bereaved controls experienced a bereavement.
Process Measures of Care
The proportion of bereaved individuals and non-bereaved controls receiving each of the processes of care in the year before and after the index (bereavement) date is shown in Table 3. Overall, attainment of all process measures was high (>70%), with the majority of patients receiving the care in both time periods. The level of attainment was lower in bereaved individuals than their controls in the year before the index (bereavement) date, but these differences reduced or disappeared in the following year. For example, for blood pressure, 94.1% of bereaved individuals had a measurement before their index (bereavement) date compared with 95.5% of matched controls, whereas both had almost identical rates after the index date. Similarly, 83.5% of eligible bereaved had their cholesterol measured in the year before bereavement compared with 87.3% of the non-bereaved controls in the matched time period, whereas in the following year, the difference was reduced to 85.5% in the bereaved compared with 86.2% in the controls.
The proportion of bereaved individuals receiving the process of care increased in the year after bereavement for all measures, whereas there were no consistent temporal changes in the control groups (Table 3). The absolute increases among the bereaved were small, between 0.3% for influenza vaccination and 2.1% for measurement of electrolytes. Self-controlled odds ratios for within-group changes in process measures of care before and after bereavement or the equivalent period for the non-bereaved are also shown in Table 3. These confirm an increase in all measures in the bereaved group, whereas in the non-bereaved group, the measures remained stable or fell slightly.
Table 4 presents unadjusted and adjusted odds ratios for comparisons between bereaved and non-bereaved individuals in the year before and after bereavement. These confirm the lower uptake in the bereaved in the year before bereavement compared with the non-bereaved controls in the same time period. In the year after bereavement, there was little difference between the two groups except for influenza vaccination, which was persistently lower in the bereaved group. Unadjusted and adjusted odds ratios from the conditional logistic model for the interaction between the bereaved and non-bereaved groups confirms that, with the exception of influenza vaccination, bereaved individuals were more likely to experience an improvement in quality of care than their non-bereaved counterparts. The unadjusted odds ratios for change were 1.29 (95% confidence interval [CI], 1.15–1.46) for cholesterol measurement, 1.40 (95% CI, 1.22–1.60) for blood pressure measurement, and 1.44 (95% CI, 1.03–2.01) for hemoglobin A1c measurement. These odds ratios were little changed by adjustment for age, deprivation, smoking, and comorbidity.
There was no evidence of consistent variation in the effect of bereavement by sex (Table II in the online-only Data Supplement). As a sensitivity analysis, we examined pre-bereavement uptake in all our bereaved subjects and their controls, irrespective of follow-up in the year after bereavement. This showed almost identical differences between the bereaved and non-bereaved in the year before bereavement and gives reassurance that the exclusion of subjects without 1-year follow-up after bereavement does not introduce systematic bias in comparison between bereaved subjects and non-bereaved controls (Table III in the online-only Data Supplement).
We further examined uptake in bereaved individuals 2 years before bereavement. This additional analysis was restricted to cholesterol and blood pressure measurements because other measures would be subject to temporal changes in patient clinical circumstances, medication use, and QOF requirements, which would make interpretation difficult. It shows higher uptake in the bereaved group 2 years before bereavement compared with 1 year before bereavement, whereas uptake in the control group remains stable in the comparable period (Table IV in the online-only Data Supplement). In other words, the lower uptake observed in the year before bereavement appears to represent a pre-bereavement deterioration in care.
We also explored results for depression screening by including a diagnosis of depression or receipt of antidepressant medication during the year as an outcome in addition to depression screening. This suggests that our findings of lower uptake in the year before bereavement may be partially explained by higher levels of diagnosed depression in the bereaved group before bereavement, leading to their exclusion from depression screening. The odds ratio for the new composite outcome, comparing bereaved with non-bereaved controls in the year before bereavement, was 0.96 (95% CI, 0.87–1.06). However, the greater increase in the bereaved group in the following year was still seen (interaction odds ratio, 1.27 [95% CI, 1.10–1.46]).
Contact with Primary Care
Contact with primary care in the 30 days, 90 days, and 1 year after bereavement and the matched time period 1 year earlier are shown in Table 5. Overall, contact with primary care was similar in each of these time periods in both groups before the index (bereavement) date. For all bereaved individuals, the mean number of contact days increased in the period after bereavement. This contrasts with non-bereaved controls whose contact remained relatively constant over the same time period. Overall, in the year after bereavement, the mean number of contact days rose to 11.2 (interquartile range, 6–14) in the year after bereavement from 9.4 (interquartile range, 4–12) in the year before.
Daily prescription coverage in the year before and after the index (bereavement) date are shown in Figure for lipid-lowering drugs, antiplatelet medication, and RAS drugs. A year before bereavement, coverage was slightly lower in bereaved compared with non-bereaved individuals for lipid-lowering and RAS drugs but similar for antiplatelet medication. Temporal trends were observed with increasing RAS drug coverage and slightly decreasing antiplatelet medication use in both groups. For all drug classes, in the bereaved group, there is a marked decrease in coverage that starts ~30 days before bereavement, peaks ~1 week after bereavement, and recovers by 90 to 120 days. The peak absolute fall in coverage is ~5% for all drug classes.
Table 6 summarizes the proportion of individuals with >80% daily prescription coverage in the 30 and 90 days after index (bereavement) date compared with a control period 1 year earlier. In bereaved individuals, the proportion of individuals with 80% coverage for antiplatelet and lipid-lowering medication coverage fell in the period after bereavement. The 30-day odds ratio for lipid-lowering drugs was 0.77 (95% CI, 0.70–0.85) and 0.75 (95% CI, 0.67- 0.84) for antiplatelet medication for self-controlled comparison in bereaved individuals. This contrasts with stable or slightly increasing coverage in non-bereaved individuals. For RAS drugs, coverage remained stable in the bereaved group but rose in the non-bereaved group.
For all medication, changes in coverage in the bereaved group in the 30 days after bereavement were unfavorable compared with non-bereaved individuals in a comparable time period. The interaction odds ratios for at least 80% coverage in the 30 days after bereavement were 0.80 (95% CI, 0.73–0.88) for lipid-lowering medication, 0.82 (95% CI, 0.74–0.91) for antiplatelet medication, and 0.86 (95% CI, 0.78–0.95) for RAS drugs. The direction of the effect was the same in both men and women, but there was a suggestion of a more marked effect in bereaved women compared with men (Table V in the online-only Data Supplement).
In the year before bereavement, older people experience lower uptake of routine annual process measures of care for cardiovascular disease compared with non-bereaved controls with recovery in the year after bereavement. Cardiovascular medication coverage falls transiently in the immediate post-bereavement period but recovers within 3 months. These differences may contribute to increased cardiovascular risk in the first weeks and months after bereavement.
Strengths and Weaknesses
Our study is based on a large unselected primary-care cohort of older couples with high existing uptake of measures of cardiovascular care. Many of the measures included in our study are incentivized in the UK QOF, which also promotes systematic recording of care. Our self-controlled, before and after, design addresses potential concern over confounding by characteristics of bereaved individuals, such as socioeconomic status, whereas our use of a parallel matched control group controls for temporal trends.
A potential weakness of our examination of processes of care is that we relied on single annual measures of care, whereas many key measures, such as blood pressure or electrolyte measurement, may be appropriately undertaken several times during a year. This approach was chosen because repeated measurement is more likely in patients with unstable or poorly controlled disease, and this may introduce bias into our comparison of bereaved and non-bereaved individuals. Our aim was to identify differences in routine care attributable to bereavement, and measurement of frequency of measures of care may potentially conflate changes in health attributable to bereavement with changes in care.
For prescribing outcomes, we used prescription coverage as a proxy for medication adherence, which is not easily measured. This approach has been used widely and relates to outcomes in individuals with cardiovascular disease.23 This means that changes in prescription coverage are likely to be meaningful in terms of their influence on patient outcomes. Our threshold of 80% coverage for cardiovascular medication is used widely in the literature as an effective proxy for identifying adherent patients.23 Furthermore, in the United Kingdom, primary care is likely to be the sole source of regular medication for older people, and issue of a repeat prescription requires an active request from the patient. This means that a reduction in prescription coverage is likely to be an effective proxy for actual adherence. Indeed, because timing for repeat prescriptions will not necessarily coincide with timing of bereavement, it is likely that our results underestimate the effect of bereavement on actual adherence because we will not capture patients who miss medication while still covered by a prescription.
Our eligibility criteria required that both bereaved and non-bereaved controls were registered for 1 full year after bereavement. This was necessary to allow 1 full year for measurement of annual processes of care but will exclude patients who die in the first year. This may exclude patients who experience cardiovascular events from our analysis, but it is likely that these patients will have a different pattern of care and more likely to be monitored and receive intervention as a result of symptoms. This means that the effect of exclusion of these patients is likely to attenuate any improvement in care in the year after bereavement but would not invalidate or reverse our findings. Furthermore, analysis of differences in uptake of care between bereaved and non-bereaved controls in the year before bereavement, irrespective of follow-up after bereavement, gave almost identical results to our main analysis restricted to those with a full year of follow-up. This suggests that our approach did not introduce artefactual differences between the comparison groups.
Finally, although date of death has been shown to be recorded with accuracy in THIN, for a few bereaved patients, we may be assigning date of bereavement slightly later than the actual date.14 This misclassification would lead to an underestimate of any early effect of bereavement, especially during the first month.
There has been relatively limited work on the quality of care after bereavement. One study assessed the impact of bereavement on six measure of care across primary and secondary care, including hemoglobin A1c measurement and influenza vaccination in a large US population.24 They found similar effects to our findings for the primary-care measures with deterioration in the period before bereavement, a marked decrease in the peri-bereavement period, and recovery after bereavement. Another smaller US study examined the quality and use of care by older patients with heart failure after bereavement. This suggested a decrease in quality of care before and after bereavement based on medication compliance.25 Other studies have confirmed the increased contact with primary care in the years after bereavement26
More studies have examined the effect of depression on medication adherence in patients with cardiovascular disease.27,28 These have shown that depression reduces medication adherence and may be a potential mediator for poorer outcomes in patients with depression. Although acute grief is distinct from depression, it does share many psychological characteristics, and our finding of reduced prescription coverage in the period after bereavement supports the relationship between psychological state and medication adherence.
Interpretation and Implications
Our finding that uptake of measures of cardiovascular care is lower in the year before bereavement and rises after bereavement to levels similar to non-bereaved individuals has a number of potential explanations. The lower uptake in the year before bereavement may reflect the stress of care giving in the year before bereavement for a subset of individuals. This explanation is consistent with studies in individuals with high levels of caregiver strain whose partner dies of dementia, in which the year after bereavement leads to an improvement in health risk behavior, including self-report measures of physician attendance and medication compliance.29
Alternatively, our findings may represent the characteristics of bereaved individuals who may have slightly poorer uptake of care related to unmeasured inherent characteristics. This is less likely because adjustment of our findings for known determinants of uptake, such as deprivation or smoking, made little difference to pre-bereavement comparisons with non-bereaved controls. In addition, analysis for cholesterol and blood pressure measurement 2 years before bereavement confirm a pre-bereavement reduction in uptake in the year before bereavement.
For the majority, bereavement leads to a worsening in psychological health, and there is evidence that health-related behaviors, such as diet and alcohol consumption, worsen after bereavement.8,30 Given this, we would anticipate worsening of uptake of care after bereavement for the majority of bereaved individuals. Thus, our findings of improvement or normalization of care in the year after bereavement are somewhat surprising. However, the increased contact with primary care after bereavement may allow increased opportunities for access to care and mitigate the potential for worsening of care after bereavement. Alternatively, the increase in uptake in the year after bereavement may also be explained by increases in symptoms or deterioration in health as a result of the stress of bereavement, which leads to the need for more care.
It is noteworthy that one element of care that appears unaffected by bereavement is uptake of influenza vaccination, which appears to be consistently lower in bereaved individuals in the year before and after bereavement. The seasonal nature of this intervention may explain this difference, although this finding warrants additional investigation because it may offer insights into approaches to reducing the impact of bereavement on quality of care. The acute effect of bereavement on medication coverage are more easily understandable and likely to be explained by the disturbance in normal functioning related to acute grief and also the practical demands of managing the death of a partner. The average prescription length in the United Kingdom is between 1 and 3 months, and this will mean that a substantial proportion of those on repeat medication for cardiovascular conditions will need a new prescription in the weeks immediately before or after bereavement.
Our findings suggest that, although small, decreases in quality of care before bereavement may contribute to increased cardiovascular risk immediately after bereavement. Our description of changes in individual measures of care may underestimate the cumulative effect of bereavement on quality of care because some patients will not receive a number of interventions and the total proportion of patients affected is likely to be greater than suggested by individual measures. Poorer monitoring in the year before death is likely to mean that individuals enter the bereavement period with poorer control of blood pressure, cholesterol, hemoglobin A1c, and electrolytes. This will raise the baseline risk of cardiovascular events and increase the absolute effect of the psychological stress of bereavement.
The decrease in medication coverage in the immediate bereavement period may have a more direct and marked effect on risk of cardiovascular events. Sudden cessation of some cardiovascular medication may lead to rebound physiological responses and increased risk of acute events.31 Increased risk has been documented after cessation of statins, aspirin, and some anti-hypertensive medication.31–35 For aspirin, a meta-analysis estimated a 3-fold increase in risk of cardiac events after cessation.35 Such effects after bereavement would markedly exacerbate the acute effects of bereavement on cardiovascular events and mortality.
The absolute impact of these changes on risk of cardiovascular events is difficult to estimate, but we conservatively estimate that 1 in 6 excess deaths after bereavement in those with existing cardiovascular disease may be attributable to changes in medication coverage (see online-only Data Supplement). The actual impact may be greater because this estimate does not take account changes to multiple medications or reduction in monitoring in the year before bereavement or non-fatal events.
In conclusion, we described changes in care for older people before and after bereavement that will increase susceptibility to acute adverse cardiovascular physiological changes induced by grief. Our findings reinforce the importance of ensuring high-quality cardiovascular care before and after bereavement. In particular, our findings suggest an important role for clinicians in encouraging and facilitating medication adherence in the immediate peri-bereavement period.
Sources of Funding
This work was supported by The Dunhill Medical Trust (grant number R169/0710). The funder had no involvement in the study design, collection, analysis, and interpretation of the data, writing of the article, or decision to submit the article for publication.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.113.004122/-/DC1.
- Received May 30, 2013.
- Accepted September 13, 2013.
- © 2013 American Heart Association, Inc.
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The year after bereavement is a period of increased risk of cardiovascular death. In addition to physiological responses to grief and lifestyle changes, changes in the quality of cardiovascular care may increase risk after bereavement. Our study identifies poorer uptake of key measures of routine care, such as lipid or blood pressure monitoring, in the year before partner bereavement with recovery in the year after bereavement. In addition, we describe a reduction in cardiovascular medication prescribing, including lipid-lowering and antiplatelet therapy, starting shortly before bereavement and lasting up to 3 months. Both these changes will adversely influence cardiovascular risk and contribute to increased cardiovascular events after bereavement. Poorer care in the year before bereavement means that individuals enter the bereavement period with higher baseline cardiovascular risk. Cessation of some cardiovascular medication, such as antiplatelet therapy, is believed to be a trigger for myocardial infarction. Improving cardiovascular care before and after bereavement has the potential for reducing the adverse health effects of bereavement. Clinicians caring for individuals whose partner is suffering from a life-limiting condition need to facilitate maintenance of normal cardiovascular monitoring and care. Such care for the partner may be appropriately included in palliative care programs. After a recent bereavement, clinicians need to encourage medication adherence and monitor prescribing coverage as part of wider social and psychological support for bereaved individuals.