Citation NR: 9714368 Decision Date: 04/25/97 Archive Date: 05/01/97 DOCKET NO. 94-31 929A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for the cause of the veteran’s death. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Crawford, Associate Counsel INTRODUCTION The veteran had active service from November 1950 to September 1953 and from September 1958 to September 1962. This appeal arises from an February 1994 rating decision in which the regional office (RO) denied entitlement to service connection for the cause of the veteran’s death. CONTENTIONS OF APPELLANT ON APPEAL The appellant, the veteran’s widow, contends that the veteran’s service-connected disability caused or contributed to cause his death. She states he experienced complications with stabilization due to excessive internal bleeding and required transfusions. DECISION OF THE BOARD The Board of Veterans’ Appeals (Board), in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), 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 evidence is in favor of the appellant’s claim of entitlement to service connection for the cause of the veteran’s death. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the appeal has been obtained. 2. The veteran died on February 17, 1993 due to sepsis syndrome, peritonitis, and a perforated sigmoid colon. Other significant conditions contributing to death but not related to cause given were severe chronic obstructive pulmonary disease (COPD), pneumonia, atelectasis, malnutrition, peptic ulcer disease (duodenitis) with bleeding requiring transfusion treatment anemia-leukopenia - thrombocytopenia, hyperglycemia and buttock and sacral decubiti. An autopsy was not performed. 3. At the time of the veteran’s death, service connection was in effect for varicose veins, a fracture of the left ring finger, and a duodenal ulcer. 4. The evidence presents a basis for concluding that the veteran’s service-connected disability contributed to cause the veteran’s death. CONCLUSION OF LAW The veteran’s service-connected disability contributed substantially or materially to cause the veteran’s death. 38 U.S.C.A. §§ 1310, 5107 (West 1991); 38 C.F.R. § 3.312 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Review of the record indicates that the appellant has submitted a well-grounded claim. The Department of Veterans Affairs (VA) therefore has a duty to assist the appellant in the development of facts pertinent to her claim. 38 U.S.C.A. § 5107. In this regard, the Board is satisfied that the VA has fulfilled it’s duty to assist. Id. In this case the appellant seeks entitlement to service connection for the cause of the veteran’s death. Pertinent law provides that, service connection may be established for a disability resulting from personal injury incurred or disease contracted in the line of duty or for aggravation of a preexisting injury or disease. 38 U.S.C.A. §§ 1110, 1131 (West 1991). The regulations also state that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (1996). Service connection may also be granted for certain chronic diseases, including cardiovascular disease, if manifest to a degree of 10 percent or more within one year from the date of separation from such service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991). In addition, entitlement to service connection may be established for the veteran’s cause of death, where the evidence shows that the disability contributed substantially or materially to cause the veteran’s death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. Id. A contributory cause of death is inherently one not related to the principal cause. In determining whether the service- connected disability contributed to death, it must be shown that it contributed substantially or materially to death; combined to cause death; or aided or lent assistance to the production of death. It is not sufficient to show that the service disability casually shared in producing death, but rather it must be shown that there was a causal connection. Id. The VA must determine whether evidence supports the veteran’s claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). In this case, the Board initially notes that at the time of the veteran’s death service connection was in effect for varicose veins, a fracture of the left ring finger, and a duodenal ulcer. The veteran’s certificate of death and amended certificate of death show that the veteran died in February 17, 1993 at the age of 59 due to sepsis syndrome, peritonitis, and a perforated sigmoid colon. Other significant conditions contributing to death but not related to cause given were severe chronic obstructive pulmonary disease, pneumonia, atelectasis, malnutrition, peptic ulcer disease (duodenitis) with bleeding requiring transfusion treatment anemia- leukopenia-thrombocytopenia, hyperglycemia and buttock and sacral decubiti. No autopsy was performed. Review of the record generally shows during service the veteran received treatment for complaints of a burning sensation in the stomach with gas and belching and that a June 1965 report of an x-ray revealed evidence of an old healed inactive duodenal ulcer. No clinical findings or typical ulcer symptoms were found. Thereafter, the record shows that from January to February 1993, the veteran was hospitalized at the Community Memorial Hospital. Those hospital reports generally show that in January, the veteran was initially admitted for complaints associated with dyspnea and severe COPD, but while hospitalized the veteran developed progressive difficulty clearing secretions and hypoxemia and became less responsive despite supplemental oxygen therapy. Because of the veteran’s condition, he was transferred to the intensive care unit where a gastroenterology consultant performed an esophagogastroduodenoscopy (EDG)and found duodenitis. In response, a peg tube was placed without difficulty and the duodenitis was treated effectively with Zantac and Carafate, as well as institution of internal nutritional support. However, gastrointestinal (GI) bleeding occurred and packed red blood cell and platelet transfusions were required. No evidence of disseminated intravascular coagulation was shown on serial screens. The veteran continued to experience abdominal discomfort and an ileus. Consequently, in February, a Gastrogaffin enema was performed. The Gastrogaffin enema showed a sigmoid colon perforation and spillage of contents into the peritoneum. An exploratory celiotomy/colotomy and repair of the sigmoid colon leak were performed. The postoperative course required mechanical ventilatory support from which the veteran was slowly weaned. The reports then show that initially, the veteran seemed to improve, as total body fluid overload responded to diuresis therapy and total parenteral nutrition was continued, but over the course of several days he was unable to clear secretions. A flexible fiberoptic bronchoscopy, right middle lobe biopsy, and therapeutic bronchoscopy were performed. Nevertheless, the veteran developed progressive weakness, additional retained secretions and acute respiratory acidosis, which exposed inadequate pulmonary reserve. On February 17, 1993, he experienced decreased blood pressure, a worsening of the acute respiratory acidosis and a decline in mentation. By midday, no evidence of cardiac, respiratory, or neurologic activity was found. The veteran was pronounced dead. The final diagnoses were acute pneumonitis; severe COPD; sepsis syndrome; duodenitis with GI bleeding; anemia; malnutrition, hyperglycemia; buttock and sacral decubiti; perforated sigmoid colon; and no known drug allergies. The evidence of record also contains an August 1994 statement from J. A. H., M.D., the veteran’s physician. In the letter, the physician stated that from January to February 1993, the veteran had experienced a protracted, complex hospitalization which included gastrointestinal hemorrhage that required blood component transfusion therapy. Thereafter, the physician stated that as the discharge summary indicates, an EDG was performed and duodenitis/peptic ulcer disease was demonstrated. He added that without question the veteran’s peptic ulcer disease contributed to his morbidity. A hand- written note on the doctor’s statement indicates that the physician, a specialist in internal medicine, felt that the peptic and duodenal ulcers were the same type of disease. In order to establish entitlement to service connection for the veteran’s cause of death, the evidence must show that the disability which caused the veteran’s death was incurred in or aggravated by service, or may be presumed to have been incurred in service, or that the veteran’s service-connected disabilities substantially or materially caused or lent assistance to cause the veteran’s death. In this case, the Board initially notes that the evidence of record does not show that the veteran incurred sepsis syndrome, peritonitis and a perforated sigmoid colon in service. As demonstrated above, service medical reports show that clinical findings associated with the veteran’s abdomen and digestive system were normal. In addition, subsequent VA examinations and hospital reports show normal clinical findings. Further, there is no medical evidence of record that directly attributes the veteran’s sepsis syndrome, peritonitis and a perforated sigmoid colon to service. Considering the foregoing, the Board concludes that the veteran’s sepsis syndrome, peritonitis and a perforated sigmoid colon were not related to service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. However, service connection for the cause of the veteran’s death may be granted if the veteran’s service-connected disabilities are shown to have caused or contributed substantially or materially to cause the veteran’s death. Although the death certificate does not indicate that the veteran’s disabilities were a factor in his death and the record shows the disabilities which were primarily responsible for the veteran’s death were not shown to be related to service, there is competent and persuasive medical evidence of record which shows that the veteran’s service- connected duodenal ulcer disability aided or lent assistance to the production of death and was causally connected to the cause of the veteran’s death. In this regard, the Board recalls that the 1993 hospital reports indicate that the veteran experienced difficulty with voiding which led to GI bleeding, requiring a packed red blood cell and platelet transfusions. The reports also indicate that as a result of complications which include the foregoing, the veteran developed progressive weakness, decreased blood pressure and acute respiratory acidosis which eventually led to death. In addition, the Board emphasizes that in August 1994, the veteran’s physician clearly stated that the veteran’s ulcer disease contributed to his demise. In view of the foregoing, the Board concludes that the evidence of record supports the appellant’s contentions which essentially maintain that the veteran’s service-connected duodenal ulcer substantially and materially contributed to the cause of the his death. Accordingly, the claim for service connection for the cause of the veteran’s death is granted. ORDER Entitlement to service connection for the veteran’s cause of death is granted. V. L. JORDAN Member, Board of Veterans' Appeals 38 U.S.C.A. § 7102 (West Supp. 1996) 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 & Supp. 1996), 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, 102 Stat. 4105, 4122 (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. - 2 -