Citation Nr: 1505928 Decision Date: 02/09/15 Archive Date: 02/18/15 DOCKET NO. 06-16 417 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Deanne L. Bonner, Attorney at Law ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from January 1959 to April 1960. He died in June 2004 and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Board remanded the case in April 2010 and, thereafter, denied the appellant's claim in a June 2011 decision. The appellant appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2012 Order, the Court granted a Joint Motion for Remand (JMR) that vacated and remanded the Board's June 2011 decision for compliance with instructions provided in the JMR. In November 2013, the Board requested an Independent Medical Expert (IME) opinion pursuant to 38 U.S.C.A. § 7109 (West 2014). This opinion was completed in January 2014, and forwarded to the appellant and her attorney for review and an opportunity to respond in March 2014. Following a July 2014 response from the Veteran's attorney, the another IME opinion was requested in August 2014 and was completed later that month. The August 2014 IME opinion was forwarded to the appellant and her attorney for review and an opportunity to respond in September 2014, and a response from the Veteran's attorney was received in January 2015. As a final preliminary matter, the Board notes that no documents are currently contained in the Veteran's Virtual VA or Veteran Benefits Management System paperless claims files. FINDINGS OF FACT 1. The Veteran's death certificate reflects that he denied in June 2004 and identified the immediate cause of death as cardiac arrest due to or as a consequence of ischemic cardiomyopathy, with diabetes type 2 noted to be a significant condition contributing to death, but not resulting in the underlying cause. 2. VA's decision to not refill a prescription for Plavix did not result in additional disability that caused the Veteran's death. CONCLUSION OF LAW The criteria for compensation under 38 U.S.C.A. § 1151 for the cause of the Veteran's death are not met. 38 U.S.C.A. §§ 1151, 1310, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.312, 3.361 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In the context of a claim for dependency and indemnity compensation (DIC) benefits, which includes a claim for service connection for the cause of the Veteran's death, section 5103(a) notice must include (1) a statement of the conditions, if any, for which a Veteran was service-connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342 (2007). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a September 2004 letter, sent prior to the initial unfavorable decision issued in September 2005, advised the appellant of the evidence and information necessary to substantiate her claim for DIC benefits based on 38 U.S.C.A. § 1151 as well as her and VA's respective responsibilities in obtaining such evidence and information. While this letter did not provide notice of the evidence and information necessary to establish a an effective date in accordance with Dingess/Hartman, supra, the Board finds no prejudice in proceeding with a decision regarding the claim. In this regard, as the Board concludes herein that the preponderance of the evidence is against the claim, any questions as to the appropriate effective date to be assigned are rendered moot. Therefore, the Board finds no prejudice to the appellant in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). Relevant to the duty to assist, the Veteran's VA treatment records regarding the medical services in question have been obtained and considered. The appellant also submitted information concerning the pharmacology associated with the medication at issue in August 2004 and March 2005, and a June 2005 private opinion in favor of the claim. She has not identified any additional relevant and outstanding records that have not been requested or obtained. Additionally, while the January 2014 IME opinion is equivocal in nature and thus insufficient to decide the instant claim, an April 2010 VA opinion and the August 2014 IME opinion addressing the matter for consideration, i.e., whether the Veteran's death was related to the non-prescription of Plavix, are adequate, in their totality, to render an equitable resolution with respect to the claim on appeal. In this regard, the medical professionals who completed these opinions considered all of the pertinent evidence of record, and included a complete rationale, relying on, and citing to, the records reviewed. Moreover, the clinicians who rendered these opinions offered clear conclusions with supporting data as well as reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a medical opinion regarding the claim for service connection for the cause of the Veteran's death has been met. See DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008). With respect to the May 2006 request from the Veteran's former representative that the VA physician involved with the medical care in question be subpoenaed, and the directives of the JMR that the Board discuss whether this request is necessary or appropriate pursuant to 38 U.S.C.A. § 5711, the Board notes that under 38 U.S.C.A. § 5711(a), VA has the authority to "(1) issue subpoenas for and compel the attendance of witnesses within a radius of 100 miles from the place of hearing . . . [and] (4) aid claimants in the preparation and presentation of claims." In 38 C.F.R. § 20.711 (2014), the Secretary defined the scope of this subpoena power to include compelling the attendance of witnesses within a radius of 100 miles from the place of hearing, and to aid in the production of "tangible evidence." Additionally, 38 U.S.C.A. § 5711 specifically states that those authorized to use the subpoena authority "shall have the power" to exercise it. As use of this power is by statute at the discretion of the Board, the Board chooses not to exercise VA's subpoena power under the circumstances of this case as the Veteran's former representative clearly requested a subpoena far outside the scope of the situations contemplated by the applicable regulation. In this regard, the VA benefits claims system does not contemplate the adversarial concepts typical of litigation that involves subpoenas. See Flynn v. Brown, 6 Vet. App. 500, 503 (1994). Moreover, the appellant was otherwise afforded multiple avenues to support her claim, to include providing her and her attorney notice of the IME opinions and the opportunity to respond to these opinions with additional evidence and argument. As such, the Board denies the request to subpoena the VA physician referenced in the May 2006 statement from the Veteran's prior representative. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the appellant in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the appellant at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis In the instant case, the Veteran's death certificate reflects that he denied in June 2004 and identified the immediate cause of death as cardiac arrest due to or as a consequence of ischemic cardiomyopathy, with diabetes type 2 noted to be a significant condition contributing to death, but not resulting in the underlying cause. The appellant contends that the Veteran ultimately died because VA failed to issue a prescription refill for his Plavix after he had requested such medication. She argues that the lack of such medication was the cause of the Veteran's death, warranting entitlement to compensation under 38 U.S.C.A. § 1151. The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. A service-connected disability will be considered the principal cause of death when such disability, singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). To be considered a contributory cause of death, it must be shown that service-connected disability contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). It is not sufficient to show that service-connected disability casually shared in producing death; rather, a causal connection must be shown. Id. Title 38, United States Code § 1151 provides compensation in situations in which a claimant suffers an injury or an aggravation of an injury resulting in additional disability or death by reason of VA hospitalization, or medical or surgical treatment, and the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or the proximate cause of additional disability or death was an event which was not reasonably foreseeable. (Emphasis added.) The regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability or death due to hospital care, medical or surgical treatment, examination, training and rehabilitation services, what is required is actual causation, not the result of continuance or the natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. The additional disability or death must not have been due to the failure to follow medical instructions. 38 C.F.R. § 3.361. To determine whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the medical treatment upon which the claim is based to his or her condition after such treatment has stopped. 38 C.F.R. § 3.361(b). To establish that VA treatment caused additional disability, the evidence must show that the medical treatment resulted in the additional disability. Merely showing that a Veteran received treatment and that the Veteran has an additional disability, however, does not establish cause. 38 C.F.R. § 3.361(c)(1). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment proximately caused a Veteran's additional disability, it must be shown that the medical treatment caused the Veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. 38 C.F.R. § 3.361(d), (d)(1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32 of this chapter. 38 C.F.R. § 3.361(d)(2). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The evidence of record reflects that the Veteran had a long medical history, including, but not limited to, diabetes mellitus insulin-dependent, coronary artery disease, hypertension, atrial fibrillation and flutter, hyperlipidemia, and obesity. As specifically pertinent to the adjudication herein, the record shows that the Veteran's prescription for Plavix was renewed on February 24, 2004 for a 90 day supply. On June 3, 2004, the Veteran he was seen for chronic renal insufficiency, and on June 9, 2004, the Veteran was seen by M.B., a VA nurse practitioner who, the appellant contends, "was concerned about" the fact that the Veteran had been prescribed Plavix and Coumadin, drugs which are essentially used to prevent the coagulation of blood. M.B. noted the concerns in a June 9, 2004, treatment note in the record. The appellant states that the Veteran was instructed by M.B. to stop taking the blood thinning drugs and resume taking them on June 17, the day after the Veteran's biopsy procedure. On June 24, 2004, the Veteran contacted Dr. W.B. via email regarding a refill. He was to be mailed a refill prescription on June 28, 2004. The medical evidence includes a June 28, 2004, addendum to the Veteran's medical record authored by Dr. W.B. that states that the Veteran called and reported that he was "out of Plavix." After review of the medical records, Dr. W.B wrote "not clear to me he continues to need[] (sic) [P]lavix." The death certificate of record indicates that the Veteran was pronounced dead at 5:49 a.m., June 29, 2004 at a private hospital after being taken there by ambulance. The immediate cause of death listed on the death certificate is cardiac arrest as a result of a 5 year history of ischemic cardiomyopathy. Such also indicated that diabetes type 2 was a significant condition contributing to death, but not resulting in the underlying cause. Detailing the events in question as asserted by the appellant in an August 2004 statement, she reported that she assisted the Veteran in maintaining his numerous prescriptions, to include ensuring that the normal procedures they employed to ensure that all prescriptions were properly and timely filled were followed. She stated that the Veteran determined he needed to refill Plavix during the time in question and made phone calls to VA to have the prescription refilled. The calls were unsuccessful, so the Veteran sent an e-mail to Dr. W.B, explaining he was "out of Plavix and a diabetes" medication. The appellant stated that, subsequent to the e-mail, the Veteran had a phone conversation with Dr. W.B who, among other things, told him he was not refilling the Plavix because he "didn't think I [the Veteran] need[ed] it." The Veteran died five days later. The appellant contends that the lack of Plavix, caused by VA's failure to refill the prescription, is the proximate cause of death. Supporting the appellant's claim is a June 2005 opinion by Dr. W.W., Ph.D., a pharmacologist and toxicologist. After review of, as stated therein, "the medical records," this opinion was as follows: The increased clotting and platelet aggregation aggravated [the Veteran's] ischemic cardiomyopathy which was listed in his death certificate as the immediate cause of his sudden cardiac arrest and death. The medical literature shows that antiplatelet function is 75 to 80% lost after 5 days of discontinuation of Plavix therapy. [The Veteran] was a high risk patient and was [due to the discontinuance of Plavix] deprived of the protection against clotting which resulted in the onset [of] ischemia of the heart, cardiac arrest, and death. In August 2005, a VA physician was unable to provide an opinion requested by the RO regarding the issue at hand because at the time he reviewed the Veteran's record, there were no records regarding the Veteran's death. Regarding the issue at hand, the appellant asked the following questions in her May 2006 substantive appeal: 1. Why was [Dr. W.B.], an internist, questioning the prescription of Plavix? 2. Why initiate action not to fill a long running stable medication regime without seeking input from cardiology prior to intervention? 3. Why did [Dr. W.B.] fail to move [expeditiously] to put [the Veteran] back on the Plavix once cardiology gave the go ahead to continue? 4. Why was [Dr. W.B.], without seeing the body, allowed to sign off on the order to skip an autopsy, proclaiming 'natural causes' when only an autopsy would reveal actual cause of death and/or any 'blood clot' factor? In an April 2010 remand, the Board requested an opinion by a VA clinician not affiliated with the VA facilities in Detroit or Ann Arbor where the treatment in question was rendered to address the claim. The requested opinion, completed later in April 2010 by a nurse affiliated with the Indianapolis VA Medical Center, which was preceded by a review of the records and consultation with the Chief Cardiologist at the Indianapolis VA Medical Center, was, as stated specifically therein, "likely as not, with[]holding Plavix for 5 days was NOT the proximate cause of the Veteran's death and was NOT due to carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault, and was NOT an event reasonably foreseeable by [Dr. W.B.]" By way of rationale, the nurse noted that the Veteran had been on Coumadin, which would be expected to prevent blood clotting. She also stated that the Veteran had a history of hematuria and that it appeared to be reasonable that Dr. W.B was concerned about the continuation of multiple anticoagulant medications. The clinician noted that the Veteran had a cardiac catheterization in 2003, at which time his excess weight was said to exceed the 350 pound limit of the VA table, that demonstrated extensive disease. She stated that upon review of the results from the catheterization with two VA physicians, it was felt that the Veteran was a reasonable target for further surgical intervention, and that this was discussed with the Veteran who responded that he wished to cautiously think about an intervention. It was noted that at that time, his weight was excessive, the angina pattern stable, and that the Veteran elected to continue medical management only. She also remarked that there were multiple co-morbid conditions that could be responsible for the Veteran's death in addition to his coronary artery disease, such as exacerbation of congestive heart failure or life threatening arrhythmia due to ischemic cardiomyopathy, diabetes, morbid obesity, sleep apnea, and multiple allergies to many cardiac medicines that would have benefited him, such as Beta blockers, digoxin, statins, and bumex. As previously noted, in November 2013, the Board sought an expert IME opinion, and the expert was asked to determine whether the criteria for compensation under 38 U.S.C.A. § 1151 were met. In this regard, the expert was specifically asked to render an opinion as to whether it was at least as likely as not that the lack of Plavix was the proximate cause of the Veteran's death and, if so, whether such was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault" by Dr. W.B., or an event not reasonably foreseeable. The requested IME opinion completed in January 2014 reflected a review of the medical history, to include as detailed above, and addressed part of the appellant's inquiries as noted in her substantive appeal. The medical expert initially found that it was not more likely as not that the Veteran died from the discontinuance of Plavix, noting as rationale the fact that the Veteran had "several significant comorbidities which may have led to his death." However, he ultimately concluded that the Veteran's death "appears to have close to, but not necessarily related, to stopping Plavix." He again noted that there were "multiple comorbidities which could have been as likely or more likely . . . the cause of death." Given the equivocal nature of the January 2014 IME opinion, another IME opinion was sought in August 2014 in order to obtain an opinion as to whether it was at least as likely as not that the failure to issue a prescription refill for the Veteran's Plavix caused his death. If it was determined that such was the case, the expert was to state whether the Veteran's death was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in not refilling the Plavix prescription, or was the proximate cause of the Veteran's death an event not reasonably foreseeable. To the extent this aspect of the opinion was negative, the expert was requested to provide a rationale for why each of the four items listed in the May 2006 substantive appeal did not represent carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA. The August 2014 IME opinion completed in response to the above request, said by the private physician to have been preceded by a review of the record, concluded that it was less than a 50 percent probability that discontinuance of Plavix was the proximate cause of death. As rationale, the medical expert provided the following: In summary, the [Veteran's] extensive cardiac history including markedly reduced left ventricular function and myocardial scar are associated with a very high rate of arrhythmic death. As clopid[o]grel [Plavix] is not a treatment for arrhythmia, I think it is [a] LESS THAN 50% probability that discontinuance of the clopidogrel was the proximate cause of the [Veteran's] death. The expert also stated that, with respect to question one by the appellant in her May 2006 substantive appeal; namely, the appropriateness of the questioning of the prescription of Plavix by Dr. W.B., that the risk of bleeding versus the benefit of antithrombotic and antiplatelet therapy [as provided by Plavix] should be questioned at each patient encounter; that current guidelines indicated that the use of Plavix longer than 12 months after a coronary stent procedure offers no additional benefit compared to aspirin alone; and that the question of continuing Plavix 12 months after a coronary stent procedure would be at the discretion of the medical provider. As for questions two and three in the May 2006 substantive appeal; namely, the failure to fill a long running stable medication regime without seeking input from cardiology and the failure to expeditiously prescribe Plavix once cardiology gave the "go ahead" to continue the medication, the expert stated that "[n]either [question] can be answered by an outside medical opinion," because the provider of care "would have the best idea about the risks and benefits of the patient's entire medical regimen, including surgical complications." As such, he stated that any comments with regard to these questions "would be merely speculation." With respect to question four in the May 2006 substantive appeal; namely, why Dr. W.B., without seeing the body, declined to order an autopsy, when "only an autopsy would reveal actual cause of death and/or any 'blood clot' factor," the medical expert stated that "lethal cardiac arrhythmia" was the most likely cause of death; that autopsy findings would not reveal an arrhythmic cause of death; and that Plavix is not a treatment for arrhythmic death prevention. He also noted that blood clot formation was common at autopsy and may not be indicative of the cause of the death, and that an autopsy in the Veteran's case would not have shown a "blood clot factor" to be the cause of death "given the [Veteran's] multitude of high risk medical problems, namely obesity, extensive cardiac disease[,] and renal disease. The Veteran's attorney argued in January 2015 that the August 2014 IME opinion was inadequate, and reduced to "speculation," because it did not address all of the questions raised by the appellant in her May 2006 substantive appeal. However, as indicated above, to prevail in a claim for benefits under 38 U.S.C.A. § 1151, it must be shown that the treatment in question resulted in additional disability and that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability or death was an event which was not reasonably foreseeable. In this regard, the August 2014 instructions to the medical expert were to only provide answers to the appellant's questions regarding the propriety of the failure to refill the Plavix prescription or the foreseeability of the Veteran's death if it was determined that failure to refill this medication caused the Veteran's death. Having found that failure to provide Plavix did not result in the Veteran's death, and particularly because the August 2014 opinion did explain why an autopsy (question four in the May 2006 substantive appeal) would not provide information as to the cause of the Veteran's death, the fact that the medical expert who completed the August 2014 opinion did not specifically address each question as to the propriety of the treatment in question raised in the substantive appeal does not render this opinion speculative or otherwise inadequate. For the same reason, the Board finds that no further "response" to the appellant's questions in her May 2006 substantive appeal is necessary in the adjudication of the claim. JMR, page 2. The Board acknowledges the positive evidence in this case, in particular, the June 2005 opinion by Dr. W.W., and, to a lesser extent given its equivocal nature, the January 2014 IME. Given the conflicting medical opinions and presuming their credibility, the Board must determine, as a question of fact, the weight of this evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Garielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). With consideration of the above in mind, the Board finds that the most probative, and thus definitive, evidence as to whether the failure to refill the Plavix prescription resulted in the Veteran's death are the April 2010 and August 2014 opinions. See Nieves-Rodriguez, supra; Stefl, supra. In this regard, these opinions reflect a more complete consideration of the Veteran's entire medical history and contain more thorough rationale than the June 2005 opinion. In this regard, both the April 2010 and August 2014 opinions discussed the multiple co-morbid conditions that could be responsible for the Veteran's death, such as diabetes, morbid obesity, sleep apnea, and extensive cardiac disease. Moreover, in contrast to the June 2005 opinion, the August 2014 IME included a detailed explanation and rationale as to why it was not the case that the deprivation of the protection against clotting by not refilling Plavix resulted in the onset of death, and that the Veteran's death was instead due a condition which is not treated with an anti-clotting agent like Plavix, namely, a lethal cardiac arrhythmia. With respect to the January 2014 IME opinion, even interpreting this opinion in a light most favorable to the appellant, given the definitive nature of the April 2010 and August 2014 medical opinions, these opinions are more probative than the equivocal January 2014 IME opinion. With regard to the information received as to the pharmacology associated with the medication at issue in August 2004 and March 2005, the Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). In this regard, the Board notes that treatise evidence must "not simply provide speculative generic statements not relevant to the Veteran's claim." Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, "standing alone," must discuss "generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Id. (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical treatise evidence must demonstrate connection between service incurrence and present injury or condition); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (generic statement about the possibility of a link between chest trauma and restrictive lung disease is too general and inconclusive); Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive (quoting Sacks, supra)). In this case, the pharmacology information submitted by the appellant only provides general information as to the nature and efficacy of the medication at issue. It is not accompanied by any corresponding clinical evidence specific to the Veteran; and does not suggest a generic relationship between the failure to refill Plavix and the cause of the Veteran's death with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. As such, the undersigned finds this information to not be relevant as to the matter for consideration and, therefore, is afforded no probative weight. Wallin, supra; Sacks, supra. The Board has considered the argument presented by and on behalf of the appellant as to the relationship between the Veteran's death and the discontinuance of Plavix. However, the undersigned finds these statements to not be competent. In this regard, such inquiries are medically complex in nature and there is no indication that the appellant or any individual who has represented her in this matter has the requisite training or knowledge to offer such an opinion. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, rendering an opinion as to whether an individual's death is the result of any VA treatment, or lack thereof, requires an understanding of a complex internal physical process pertaining to the nature and causes of his death, which is beyond the scope of the appellant or any person who has represented her in this matter. Therefore, as none of these individuals are competent to render an opinion as to whether the failure to refill the Veteran's Plavix prescription resulted in additional disability so as to cause his death, the Board accords such statements no probative weight. In short, and the while the Board is sympathetic to the circumstance which led to the Veteran's death, the Board finds that the preponderance of the evidence is against the claim for compensation under 38 U.S.C.A. § 1151 for the cause of the Veteran's death. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for the cause of the Veteran's death is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs