BVA9505113 DOCKET NO. 93-01 677 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD J. L. Prichard, Associate Counsel INTRODUCTION The veteran had active service from May 1943 to October 1945. After developing additional evidence in this case, the Board of Veterans' Appeals, in accordance with Thurber v. Brown, 5 Vet. App. 119 (1993), informed the representative in a letter dated in February 1995 of the additional evidence developed, and provided an opportunity to respond. The representative, in March 1995, responded that he had no further evidence, argument, or comment to present. CONTENTIONS OF APPELLANT ON APPEAL The appellant, widow of the veteran, contends that she is entitled to service connection for the cause of the veteran's death. She states that the veteran was service-connected for bronchitis at the time of his death, and notes that one of the immediate causes of the veteran's death included respiratory failure. The appellant argues that the veteran's bronchitis cannot be disassociated from the respiratory failure. She also believes that the bronchitis could have predisposed the veteran to the infection which resulted in sepsis, which was the underlying cause of the veteran's death. DECISION OF THE BOARD The Board of Veterans' Appeals (Board), in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the appellant's claim for service connection for the cause of the veteran's death. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the RO. 2. The veteran's sepsis was not shown in service, was first demonstrated many years following discharge from active service, and is not related to active service. 3. The evidence shows that the veteran's service-connected disabilities, pes planus and chronic bronchitis, were not a principal or contributory cause of death, and that there was no etiological relationship between the service-connected disabilities and the causes of the veteran's death. CONCLUSIONS OF LAW 1. Sepsis, the cause of the veteran's death, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991). 2. A service-connected disability did not cause the veteran's death or contribute substantially or materially to cause the veteran's death. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the appellant's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107. That is, we find that she has presented a claim which is plausible. We are also satisfied that all relevant facts have been properly developed. The record is devoid of any indication that there are other records available which might assist the Board in reaching a decision. The record is complete, and no further assistance to the appellant is required to comply with the duty to assist the appellant mandated by 38 U.S.C.A. § 5107. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. 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. The service- connected disability is considered the principal cause of death when such disability, either singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related to the cause of death. To be a contributory cause of death, it must be shown that the service- connected disability contributed substantially or materially to cause death, that it combined to cause death, or that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather is must be shown that there was a causal connection. 38 C.F.R. § 3.312. Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. Service-connected diseases or injuries affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other diseases or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). At the time of the veteran's death, his service-connected disabilities were chronic bronchitis and pes planus. These disabilities were each evaluated as zero percent disabling. The May 1992 death certificate shows that the veteran was born in June 1908 and died in May 1992. The immediate cause of death was shock and respiratory failure, with sepsis listed as the underlying cause. Other significant conditions which contributed to death but did not result in the underlying cause included hyponatremia, and hyperkalemia. Bronchitis was not listed as a cause of death. Sepsis is the presence in the blood or other tissues of pathogenic microorganisms or their toxins. Dorland's Illustrated Medical Dictionary 1400 (25th ed. 1974). Shock is the condition of acute peripheral circulatory failure due to derangement of circulatory control or loss of circulating fluid. It is marked by hypotension, coldness of the skin, usually tachycardia, and often anxiety. Septic shock is shock developed in the presence of severe infections. Dorland's Illustrated Medical Dictionary 1409 (25th ed. 1974). After careful review of the evidence of record and the appellant's contentions, the Board is unable to find that the causes of the veteran's death are related to active service. The death certificate states that shock and respiratory failure developed as a result of sepsis, and the record indicates that sepsis first appeared many years following discharge from active service and immediately prior to the veteran's death. There is no indication that the veteran's bronchitis was active, or related to his respiratory failure. The service medical records are entirely negative for any evidence of an infection of the blood or other tissues. The earliest medical evidence of sepsis is the May 1992 hospital records from the veteran's final hospitalization. These records show that the veteran had been residing in a nursing home, and was admitted to the hospital through the emergency room. There were vague complaints that the veteran had vomited blood and was not doing well. He was found to be hypotensive and febrile on admission. He responded to verbal and painful stimuli, but not verbally. The laboratory data were abnormal, including abnormal liver function tests and an abnormal level of electrolytes. He was admitted for possible urosepsis, to be treated in order to correct his electrolytes and other metabolic abnormalities. His past medical history included urosepsis, hypokalemia, diabetes, malnutrition, hyponatremia, and seizure activity, as well as complete bundle branch block, myocardial infarction, and multiple decubitus ulcer which needed diversion colotomy. Bronchitis was not noted in the discussion of the veteran's medical history. On examination, the veteran's respiration was normal. The lung sounds were found to be basically clear, except for a few scattered rhonchi and rales bilaterally. The impression was of septic shock, dehydration with azotemia and mild renal failure, malnutrition, hyponatremia, hyperkalemia, and Dilantin toxicity. The May 1992 hospital summary further indicates that the veteran's critical condition was explained to his family. The lungs were said to be clear. The veteran was noted to have been started on hydration. Blood cultures and urine cultures had been obtained, and he was started on several medications. However, the veteran did not respond to treatment, and he gradually deteriorated until he finally expired. The veteran's blood culture was noted to have grown proteus mirabilis sensitive to Rocephin and gentamicin. The final diagnoses were sepsis with proteus mirabilis, septic shock, renal failure, malnutrition, hyponatremia, hyperkalemia, Dilantin toxicity, history of a seizure disorder, history of left cerebrovascular accident, and Parkinson's disease. The evidence does not show that the veteran developed sepsis as a result of active service. The service medical records are completely negative for sepsis or a related disorder, and the evidence indicates that he did not develop sepsis or a related disorder until approximately 47 years following discharge from active service. The evidence also fails to show that the veteran's service- connected disabilities contributed to cause his death. The veteran's pes planus did not affect a vital organ, and there is no evidence to show that it was in any way related to his death. The appellant has not advanced any contentions pertaining to this disorder. Chronic bronchitis is also unrelated to the cause of the veteran's death. Neither the death certificate or the report of the veteran's final hospitalization contains any reference to bronchitis, and this disorder was not included in any of the relevant medical histories. Although a few rales and rhonchi were reported, the May 1992 hospital report indicated that the lungs were basically clear, and active bronchitis was not diagnosed. In addition, no evidence has been submitted to demonstrate that bronchitis made the veteran susceptible to the infection which led to sepsis, or rendered him less capable of resisting the effects of sepsis. The final diagnosis was sepsis with Proteus mirabilis. The proteus species of bacteria are found regularly in the mammalian intestine. They are urease- producing bacteria, which break down urea to ammonium, and are frequently associated with stones of the urinary tract. Frits Orskov, M.D., and Ida Orskov, M.D., Enterobacteriaceae in Infectious Diseases and Medical Microbiology 296 (Abraham I. Braude, M.D., Ph.D., et al. eds., 2nd ed. 1986). The Board notes that while the death certificate lists respiratory failure as an immediate cause of death, the final hospitalization report is silent for respiratory failure. However, the hospital report did include a diagnosis of renal failure, which was excluded from the death certificate. Also, the veteran was initially admitted for urosepsis, and had abnormal liver functions. As the proteus mirabilis found in the veteran's blood is more commonly associated with the urinary and digestive tracts and the veteran had difficulties in these areas, and as no medical evidence has been submitted to show that bronchitis predisposed the veteran to infection from this bacteria, it cannot be assumed that the infection was the result of bronchitis without resorting to speculation. Neither the appellant or her representative are qualified to make such a medical determination. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Since the preponderance of the evidence shows that the cause of the veteran's death, sepsis, was not manifest until many years after service and was not related to his service-connected disabilities, and since the service-connected disabilities did not contribute in any way to cause his death, service connection for the cause of death is not warranted. ORDER Entitlement to service connection for the cause of the veteran's death is denied. WILLIAM J. REDDY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.