Citation Nr: 1305752 Decision Date: 02/19/13 Archive Date: 02/27/13 DOCKET NO. 06-00 693 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty from June 1942 to August 1944. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The appellant is the Veteran's widow. In December 2008, the Board issued a decision which denied the appellant's claim herein. Thereafter, the appellant appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In October 2009, based on a Joint Motion for Remand (Joint Motion), the Court issued an Order remanding this case for compliance with the Joint Motion. Accordingly, the Board's December 2008 decision was vacated and the Board remanded the appellant's case in May 2010 and October 2011 for further evidentiary development. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. A June 2004 certificate of death indicates that the Veteran died in a hospital in June 2004 at the age of 84. The certificate of death lists the immediate cause of death as cardiopulmonary arrest due to or as a consequence of respiratory failure, and chronic obstructive pulmonary disease (COPD). An autopsy was not performed. 2. At the time of the Veteran's death, service connection was in effect for weakness of the right upper extremity, with atrophy of the right hand and substantial loss of use of the dominant extremity; weakness of the right lower extremity, with partial foot drop; and old compression fracture C-5, C-6, with secondary hypertrophic changes. 3. The probative evidence of record does not show that the cause of the Veteran's death was related to his active military service or to his service-connected disabilities. CONCLUSION OF LAW A disability incurred in or aggravated by service did not cause or contribute substantially or materially to cause the Veteran's death. 38 U.S.C.A. §§ 1110, 1310, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION With respect to the appellant's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. With regard to the appellant's claim for entitlement to service connection for the cause of the Veteran's death, the appellant was provided a notification letters in July 2004 and May 2010 that satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Hupp v. Nicholson, 21 Vet. App. 342 (2007), rev'd on other grounds, Hupp v. Shinseki, 329 Fed. App. 277 (2009). The Board acknowledges that the May 2010 letter was not sent prior to the initial adjudication of the claim; however, the claim was readjudicated by the August 2012 supplemental statement of the case. Therefore, any defect in the timing of the notice of this information was harmless. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). Further, the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). Next, VA has a duty to assist the appellant in the development of her claim. This duty includes assisting her in the procurement of service treatment records and other pertinent records, and providing a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records. The appellant and her daughter submitted private treatment records and written statements discussing their contentions. Neither the appellant nor her representative has identified any outstanding pertinent evidence related to the claim for entitlement to service connection for the cause of the Veteran's death. In addition, VA medical opinions with respect to the claim on appeal were obtained in August 2005, February 2006, August 2011, and December 2011. VA's duty to assist additionally specifically includes providing a medical opinion when necessary if the claim at issue involves disability compensation. 38 U.S.C.A. § 5103A(d); 38 C.F.R. §§ 3.159(c)(4), 3.326. In the context of Dependency and Indemnity Compensation claims, provision of a medical opinion or other medical analysis is pursuant to 38 U.S.C.A. § 5103A(a) rather than the above cited statute and regulations which pertain only to claims for disability compensation. DeLaRosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008); Wood v. Peake, 520 F.3d 1345 (Fed. Cir. 2008). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the December 2011 VA medical opinion obtained in this case is more than adequate, as it is predicated on a full reading of the private and VA medical records in the Veteran's claims file. In particular, the examiner considered the pertinent evidence of record and the statements of the appellant, and provided a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA opinion in this appeal has been met. 38 U.S.C.A. § 5103A(a). The available records and medical evidence have been obtained in order to make adequate determinations as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The appellant contends that the Veteran was unable to recover from open heart surgery because his service-connected disabilities prevented him from walking and therefore contributed to his death three months after surgery. When any veteran dies after December 31, 1956, from a service-connected or compensable disability, VA will pay dependency and indemnity compensation to such veteran's surviving spouse, children, and parents. 38 U.S.C.A. § 1310. In a claim where service connection was not established for the fatal disability prior to the death of the veteran, the initial inquiry is to determine whether the fatal disorder had been incurred in or aggravated by service. The Board must determine whether the fatal disorder should have been service-connected. 38 C.F.R. § 3.312. A service-connected disability is the principal cause of death when that disability, "singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto." 38 C.F.R. § 3.312(b). A service-connected disability will be considered as the contributory cause of death when that the disability contributed substantially or materially to death, combined to cause death, or aided assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Service-connected diseases involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, with debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c). In order to be a contributory cause of death, it must be shown that there were "debilitating effects" due to a service-connected disability that made the veteran "materially less capable" of resisting the effects of the fatal disease or that a service-connected disability had "material influence in accelerating death," thereby contributing substantially or materially to the cause of death. Lathan v. Brown, 7 Vet. App. 359 (1995); 38 C.F.R. § 3.312(c)(1). The Veteran's service treatment records are negative for any diagnosis or indication of a heart or lung disorder. In October 1943, the Veteran was injured while riding on top of a load of coal when an overhead wire hit his neck and threw him to the ground. He suffered multiple injuries, including a right wrist fracture and cervical vertebra compression fracture. A post-service October 1944 VA neuropsychiatric examination listed a diagnosis of traumatic cord lesion of the lower cervical segment. A March 1948 VA examination report reflected a diagnosis of traumatic lesion of the lower cervical spinal cord, with weakness in the right extremities, atrophy and sensory change in the right upper extremity, and sensory change in the left lower extremity and lower part of the body on the left. A January 1959 VA orthopedic examination report showed findings of partial, spastic type, paralysis of the right upper and lower extremities, with impairment of superficial sensation in the left half of the boy, secondary to cervical spine fracture at the C5 and C6 level, with cord injury. A January 1959 VA neuropsychiatric examination report revealed a diagnosis of spinal cord injury at level C4, C5, and C6 with chronic, moderately severe residuals of weakness on entire right side of the body, atrophy, reflex changes, pain, and vibratory changes. The Veteran received private treatment for left knee degenerative arthritis in September 1976. A November 1976 VA special neuropsychiatric examination report showed a diagnosis of spinal cord injury of the lower cervical area, with weakness in the right upper extremity and atrophy of the right hand, with hyperactive reflexes on the right side of the body. Treatment records dated in March and April 2004 from Immanuel Medical Center were associated with the record. A March 2004 history and physical report listed an assessment of atrial fibrillation, congestive heart failure, COPD, and hypertension. In a March 2004 cardiovascular consultation, the examiner noted that the Veteran was a very active individual who golfed, cared for himself, and lead an active lifestyle. The Veteran reported increasing edema and shortness of breath, requiring hospitalization. The diagnosis was severe mitral insufficiency and chronic atrial fibrillation. The examiner recommended mitral valve repair or possible replacement and ablation to resolve atrial fibrillation. In a March 2004 operative report, it was indicated that the Veteran underwent a mitral valve replacement. The post-operative diagnosis was severe mitral insufficiency, moderate tricuspid and aortic insufficiency, as well as chronic atrial fibrillation. An April 2004 discharge summary detailed that the Veteran was discharged in "fairly good" condition and that his incisions were healing well. He was on oxygen and still slightly short of breath. The examiner noted that the Veteran refused to do his incentive spirometry (a bronchial improvement exercise) and refused to walk if it did not fit into his time schedule; therefore, the Veteran was transferred to another facility, Immanuel Fontenelle Home, for continued rehabilitation. The Veteran was afebrile at discharge and in an atrial fibrillation, with a controlled ventricular rate. An April 2004 discharge summary from Immanuel Fontenelle Home detailed the Veteran's short stay at that facility for rehabilitation, prior to readmission to Immanuel Medical Center. Admitting diagnoses were mitral/aortic stenosis, congestive heart failure, and cerebrohepatorenal syndrome. Medically defined conditions were listed as mitral regurgitation, aortic insufficiency, cervical spine fracture with right hemiparesis, paroxysmal atrial fibrillation, tachycardia, hypertension, basal cell carcinoma, COPD, renal failure, brachycardia, and direct current conversion. It was noted that the Veteran was easily fatigued; needed continuous oxygen; had impaired mobility; was unable to tolerate long periods of therapies; and required extensive assistance. An April 2004 emergency report from Immanuel Medical Center detailed that the Veteran had lost his pulse; did not have very good respirations; had dyspnea and pneumonia; and was transferred to the intensive care center. Additional private treatment records from Immanuel Medical Center dated in April 2004 revealed a post-operative stay for hypotension, renal failure, atrial fibrillation, and bradycardia. The examiner noted that a physical therapy note indicated that the Veteran required minimum assistance with supine to sit transfers and minimum assistance of two people for stand-pivot transfers to the chair. The Veteran complained of fatigue and was noted to have limited participation. An occupational therapy note from the prior day indicated that the Veteran refused all forms of moving, secondary to increased fatigue. The Veteran reported that there was independence with ambulation and activities of daily living prior to hospitalization, but that he currently had fatigue and shortness of breath. In an April 2004 electrophysiology consultation report from that facility, it was noted that the Veteran went into atrial fibrillation after mitral valve surgery and was treated with three cardioversions, but reverted back into atrial fibrillation. He was discharged after surgery with atrial fibrillation, but was readmitted with atrial fibrillation with a rapid ventricular response as well as increasing shortness of breath, heart failure, and questionable pneumonia as well as renal failure. In an April 2004 cardiology consultation report from Immanuel Medical Center, the Veteran was noted to have no exercise or physical movement for the prior month; however, previous to this, he reported that he used to be very active by exercising four times per week and frequently playing golf. It was noted that there was some weakness in the right arm and some wrist drop due to the broken neck injury. An April 2004 private medical record from J. M., M. D. showed that the Veteran was treated with biphasic shocks in an attempt to convert the heart to a sinus rhythm. The sinus rhythm returned and the diagnosis was atrial fibrillation, status post mitral valve replacement and tricuspid valve annuloplasty ring repair, and successful direct current cardioversion from atrial fibrillation back to normal sinus rhythm. A May 2004 admit history and physical report from Select Specialty Hospital showed an assessment of COPD exacerbation, acute renal failure, status post mitral valve replacement, status post mitral valve repair, history of atrial fibrillation now in sinus rhythm, deconditioning, history of hypertension, history of gastro-esophageal reflux, and history of basal carcinoma. A May 2004 report of consultation from Dr. M. detailed that the Veteran was readmitted and was now in Select Specialty Hospital after the March 2004 valve repair because of atrial fibrillation, shortness of breath, and heart failure. The examiner explained that because the Veteran was cardioverted so many times, it was elected to leave him in atrial fibrillation/flutter and consult regarding "AV" nodal oblation and permanent pacemaker implantation. Diagnoses included atrial fibrillation, with rapid ventricular response; chronic atrial fibrillation; history of severe mitral regurgitation; tricuspid regurgitation, status post mitral valve replacement; tricuspid valve annuloplasty and ring repair late March 2004; postoperative course complicated by multiple episodes of recurrent atrial fibrillation refractory to multiple cardioversions and loading large doses of Amiodarone therapy; and no significant coronary artery disease per cardiac catheterization in March 2004. The plan was medical management and consideration of "AV" nodal oblation and permanent pacemaker implantation. Additional physical and occupational therapy notes dated in May and June 2004 from Select Specialty Hospital reveal that the Veteran repeatedly agreed to participate in therapy and sometimes was not feeling able to participate. He was noted to require maximum assistance and fatigued very quickly. A June 2004 operative report revealed that the Veteran underwent a panendoscopy after a gastrointestinal bleed. A June 2004 consultation report for rehabilitation recommendations noted the Veteran's past medical history included injuries during World War II. The appellant was noted to inform the treatment provider that the Veteran broke his neck in two places, with subsequent weakness in the right upper and lower extremity, as well as had right foot drop, with right side limping since his war injury. The examiner listed an impression of impaired mobility, mild confusion, history of mitral valve replacement, dysphasia status post percutaneous endoscopic gastrostomy tube, lower extremity edema, anemia, history of hypertension, and history of COPD. A June 2004 discharge summary from Select Specialty Hospital listed the final diagnoses as enterococcus faecalis bacterermia; enterococcus faecalis urinary tract infection; methicillin-resistant Staphylococcus aureus pneumonia; acute renal failure; hypokalemia; hypernatremia; iron deficiency anemia; diverticular bleed; chronic atrial fibrillation; severe mitral regurgitation; status post valve replacement and Maze procedure; malnutrition; dysphagia with percutaneous endoscopic gastrostomy tube; coronary artery disease; and COPD. As noted above, the Veteran died at the hospital in June 2004 at the age of 84. The certificate of death lists the immediate cause of death as cardiopulmonary arrest due to or as a consequence of respiratory failure due to or as a consequence of COPD. An autopsy was not performed. At the time of the Veteran's death, service connection was in effect for weakness of the right upper extremity, with atrophy of the right hand and substantial loss of use of the dominant extremity; weakness of the right lower extremity, with partial foot drop; and old compression fracture C5, C6, with secondary hypertrophic changes. In a March 2005 statement, the appellant asserted that the Veteran's service-connected disabilities contributed to his death. She reported that after the open heart surgery, medical professionals advised the Veteran that he had to walk to recover. She further indicated that due to the severe weakness of the right side of the Veteran's body and compromised right hand, caused by war-related injuries, it was too much for the Veteran to try to walk. She reiterated that the Veteran died less than three months after his surgery of respiratory failure. In an August 2005 VA medical opinion, a VA physician found that the Veteran had severe valvular disease; severe mitral insufficiency, with moderate tricuspid; and aortic insufficiency, along with atrial fibrillation and extreme difficulty being cardioverted. The Veteran was also noted to have hypertension, COPD, reflux disease, tobacco abuse, renal insufficiency, post-operative anemia, pulmonary hypertension, and a pleural effusion. The physician stated that there was no documentation in the claims file mentioning any recent difficulties with the right upper and lower extremities or the neck. The physician stated that without more medical records to evaluate, it would be mere speculation to opine whether the weakness of the right upper and lower extremities and neck issues rendered the Veteran incapable of participating in the necessary physical activity following open heart surgery in March 2004, thereby contributing to his death. The physician stated that if the RO obtained the entire hospitalization record, the physician would review those records and provide an additional opinion. In an August 2005 rating decision, the RO indicated that a clear and unmistakable error was found with respect to the evaluations for right upper extremity weakness, right lower extremity weakness, and old compression fracture of the cervical spine, assigning increased evaluations on an accrued basis. In addition, the RO granted entitlement to service connection for marked analgesia and dysesthesia below the nipple line, extending down to left leg, diminished sense of position and vibratory sense in left lower extremity on an accrued basis. The RO also awarded entitlement to special monthly compensation based on loss of use of one hand on an accrued basis. 38 U.S.C.A. § 1114(k); 38 C.F.R. § 3.150(a). In the August 2005 decision, the Veteran's service-connected disabilities were considerable weakness of the right upper extremity, with clawing, limitation of motion of hand, significantly diminished grasp strength in the dominant extremity; weakness, right lower extremity with partial foot drop; and old compression fracture C5, C6, with secondary hypertrophic changes; and marked analgesia and dysesthesia below the nipple line, extending down to left leg, diminished sense of position and vibratory sense in left lower extremity. In a February 2006 VA medical opinion, the same physician from the August 2005 VA medical opinion opined that the Veteran's right upper and lower extremity disabilities and old compression fractures of C-5, C-6 did not lead to his inability to recover from open heart surgery, thereby contributing to his death. The physician explained that the severe cardiac problems that the Veteran had were the main items leading to his demise and that there was abundant documentation that his heart issues were quite severe. The physician stated that medical staff had an extremely difficult time trying to cardiovert and keep the heart in sinus rhythm. There was atrial fibrillation and atrial flutter, with a rapid ventricular response, which was hemodynamically not stable. There was also respiratory failure and congestive heart failure, mitral valve replacement and tricuspid valve annuloplasty, and a history of atrial fibrillation, which was not able to be returned permanently to sinus rhythm. Thereafter, the physician opined that cardiac issues were the items that contributed to the Veteran's death because of the inability to return to a normal sinus rhythm and complications therefrom. The physician noted that the full medical evidence submitted by the appellant had been reviewed. In a June 2010 lay statement, the daughter of the appellant and Veteran asserted that she was a frequent visitor during the Veteran's hospitalization, approximately three months prior to his death. She indicated that the Veteran hindered from participating in physical therapy because he could not grip his walker with his "bad" right hand, had no strength in his upper right arm, and his right leg would give out when he tried to take a step. It was her impression that the Veteran finally started to refuse therapy because he felt he unable to do it. In an August 2011 VA medical opinion, the examiner discussed his review of the claims file. The examiner opined that the Veteran's service-connected disability did not cause or contribute to the Veteran's death. The examiner highlighted that the Veteran's real contributing factors were his underlying lung disease, valvular heart disease with biatrial enlargement, and persistent atrial fibrillation, noting that the Veteran's documented deconditioning immediately "post op" with respiratory failure and renal failure all were the cause of his demise. The examiner also addressed the assertion of the appellant that the Veteran was unable to recover from open heart surgery because his service-connected disabilities prevented him from walking and therefore contributed to his death. However, the examiner determined based on his review of the skilled nursing physical therapy/occupational therapy records that the Veteran's limiting factor for rehab was dyspnea and even hypoxia, with physical activity. In a December 2011 VA medical opinion, the examiner discussed his review of the Veteran's claims file, referencing multiple pieces of evidence from the file. Thereafter, the examiner opined that the Veteran's service-connected disabilities did not cause or contribute substantially to the Veteran's death. In his cited rationale, the examiner indicated that the Veteran died from numerous medical and post-surgical complications related to his numerous underlying co-morbidities, as predicted by a validated Society of Thoracic Surgeons score. The Board finds that service connection for the cause of the Veteran's death is not warranted. As an initial matter, there is no factual basis in the record that a heart or lung disorder was incurred during service, or manifested as a chronic disease within a year thereafter, or for several decades after his discharge from service. Service treatment records did not reflect findings of a heart or lung disorder during service. Post-service medical evidence of record first showed findings of a heart or lung disorder many years after the Veteran's separation from active service in 1944. The passage of many years between discharge from active service and the continuity of symptomatology or medical documentation of a claimed disability are factors that tend to weigh against a claim for service connection. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Significantly, the record also does not include any medical evidence or opinion even suggesting a causal relationship between the Veteran's fatal heart and lung disorders and his active military service, and neither the appellant nor her representative has identified or even alluded to the existence of any such opinion. Thus, there is no basis upon which to conclude that the Veteran's immediate cause of death was incurred in or aggravated during military service, including on a presumptive basis. 38 C.F.R. § 3.303, 3.307, 3.309 (2012). It is uncontroverted that service connection was granted for right upper and bilateral lower extremity disabilities, as well as a cervical spine disability. However, the probative evidence of record does not indicate that the Veteran's service-connected disabilities were a contributory cause of his death from cardiopulmonary arrest, due to or as a consequence of respiratory failure, due to or as a consequence of COPD. The VA physician in December 2011, provided an adequate and concise opinion concerning whether the Veteran's service-connected disabilities were a contributory cause of his death after thoroughly reviewing the Veteran's entire claims file. Based on such review, the VA physician specifically opined that the Veteran's service-connected disabilities did not cause or contribute substantially to the Veteran's death, finding that the Veteran died from numerous medical and post-surgical complications related to his numerous underlying co-morbidities as predicted by a validated Society of Thoracic Surgeons score. Additional VA examiners came to the similar conclusions in February 2006 and August 2011 VA medical opinions of record. In fact, there is no probative medical evidence of record which indicates that any of the Veteran's service-connected disorders caused or contributed substantially or materially to the Veteran's cause of death. Under these circumstances, the Board concludes that the most probative evidence on the question of whether the Veteran's service-connected disabilities were a contributory cause of his death weighs against the claim of entitlement to service connection for the cause of the Veteran's death. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) ("It is the responsibility of the BVA to assess the credibility and weight to be given the evidence.") (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The appellant and her daughter's statements that the cause of the Veteran's death was related to his service-connected disabilities are not competent evidence of the etiology of the Veteran's cause of death requires medical diagnosis based on diagnostic tests, which the appellant is not trained to perform. See Jandreau v. Nicholson, 492 F.3d at 1377 (holding that whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the United States Court of Appeals for Veterans Claims). The Board is cognizant that the appellant and her daughter's statements are competent evidence as to observable symptomatology, to include upper and lower extremity weakness and instability. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions); Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable, symptoms of disability"). However, the statements that the Veteran's death was caused by or contributed to by his service-connected disorders draw medical conclusions which the appellant and her daughter are not qualified to make. Although lay persons are competent to provide opinions on some medical issues, the etiology of the Veteran's cause of death falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau, 492 F.3d at 1377. Accordingly, the claim for service connection for the cause of the Veteran's death must be denied for the foregoing reasons. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to service connection for the cause of the Veteran's death, the doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs