Citation Nr: 1319175 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 08-36 098 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington THE ISSUE Entitlement to service connection for the cause of the Veteran's death. ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran served on active duty from October 1942 to March 1946. The Veteran died in March 2000, and the appellant is the Veteran's surviving spouse. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision of the RO in Seattle, Washington, which determined that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for cause of the Veteran's death. In April 2012, the Board concluded that reopening was warranted for the claim and remanded for additional development. The Board remanded this appeal again in January 2013. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran died on March [redacted], 2000, as the result of Parkinson's disease and coronary artery disease. 2. During his lifetime, the Veteran was service connected for dysentery, rated as 10 percent disabling. 3. Parkinson's disease and coronary artery disease were not present during the Veteran's period of active service, continuously present since service, manifest to a compensable degree within one year of service separation, and are not otherwise directly related to an incident of service. 4. The Veteran's service connected dysentery did not cause or aggravate any of the medical conditions that caused his death, nor did the dysentery cause or contribute substantially or materially to cause the Veteran's death. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1131, 1310, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist With respect to the appellant's claim, 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). VA 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). In the context of a claim for cause of death benefits, 38 U.S.C.A. § 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 cause of death claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a cause of death claim based on a condition not yet service connected in order to satisfy the first Quartuccio element. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). A June 2006 letter was sent to satisfy the duty to notify provisions prior to initial adjudication of the appellant's claim in August 2006. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. This letter satisfied all the above requirements, except that the RO did not include a statement of the conditions for which the Veteran was service-connected during his lifetime. The Veteran was only service-connected for dysentery during his life. The appellant has submitted numerous statements in support of her claim contending with specificity that the Veteran's service-connected dysentery contributed to his death. In light of the appellant's actual knowledge of the Veteran's service-connected disability, the Board finds that the error in failing to provide notice of the third Hupp element, viz., notice of those conditions for which the Veteran was service-connected at the time of his death, was harmless. See Shinseki v. Sanders, 129 S.Ct. 1696, 1708 (2009); Mlechick v. Mansfield, 503 F.3d 1340, 1345 (2007). The Board also remanded this appeal in April 2012, in part to provide Hupp compliant notice, because the initial notice and adjudication of this claim occurred prior to the Hupp decision. The Appeals Management Center (AMC), which developed this case on remand, sent fully Hupp compliant notice in June 2012. The appellant had a chance to respond, did so in July 2012, and her claim was readjudicated in November 2012 and March 2013 supplemental statements of the case. Any possible error has been corrected with this notice. See Mlechick, 503 F.3d at 1345. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant identified records at the St. Mary's Medical Center and SunBridge Care and Rehabilitation facility in Walla Walla, Washington. The appellant has reported that the SunBridge facility has gone out of business. The Board finds that any attempt to obtain records from this source would be futile. The Board remanded to assist the appellant in obtaining records from St. Mary's. She provided a May 2012 release form without the necessary addresses. Following a June 2012 follow up contact, the appellant provided an authorized release form completed except for the facility information, and a separate list of all the facilities at which she believed that relevant records might be found, including the necessary addresses. The RO took no action following this submission, despite having all necessary documents to obtain the outstanding records. By their own terms, authorized release forms are only valid for 180 days after signature. The Board remanded to provide the appellant another opportunity to provide an authorized release form. The AMC contacted her in February 2013, requesting another authorized release form for St. Mary's. She did not respond. The Board finds that the AMC could not obtain the records identified. The appellant also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As such, the Board will decide this matter based on the evidence of record as it currently stands. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. In cause of death cases, a medical examination or opinion is necessary if there is competent evidence to establish the cause of death, an indication that the cause of death may be associated with service or a service connected disability and insufficient medical evidence to render a decision on the claim. See Daves v. Nicholson, 21 Vet. App. 46, 50-51 (2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). While 38 U.S.C.A. § 5103A(a) does not always require VA to assist a claimant in obtaining a medical examination or assistance, such assistance is required whenever a medical opinion is necessary to substantiate the claim, and VA is excused from providing such assistance only when no reasonable possibility exists that such assistance would aid in substantiating the claim. Wood v. Peake, 520 F.3d 1345, 1347 (Fed. Cir. 2008). The Board finds that the duty to provide an examination or opinion is not triggered based on any possible theory of entitlement. First, the Veteran's cause of death was listed as due to Parkinson's disease and coronary artery disease. As the cause of death is known, an autopsy is not warranted. Daves, 21 Vet. App. at 51. Second, the appellant does not contend and the evidence does not otherwise suggest that the Veteran's Parkinson's disease or coronary artery disease were present during service, continuously present since service, manifest to a compensable degree within one year of service separation, or are otherwise directly related to an incident of service. The theory of entitlement is not reasonably raised by any competent evidence, lay or medical; thus, VA's duty to provide an examination or opinion under 38 U.S.C.A. § 5103A(a) is not triggered. Wood, 520 F.3d at 1348. Third, and as will be discussed at length below, the preponderance of the evidence demonstrates that the Veteran's service-connected dysentery did not cause or aggravate any of the medical conditions that caused his death, nor did the dysentery cause or contribute substantially or materially to cause the Veteran's death. The appellant alleges that the Veteran's service-connected dysentery resulted in dehydration that accelerated his death by Parkinson's disease. The Veteran's medical records in the three years leading up to his death do not, however, show that he was actually dehydrated. The Board finds that there is no reasonable possibility that a medical opinion would assist the appellant in substantiating her claim. Thus, the duty to provide an examination or opinion under 38 U.S.C.A. § 5103A(a) is not triggered by the appellant's contentions. Wood. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded this case twice, in April 2012 and January 2013. The April 2012 remand instructed that the appellant be provided adequate notice under the duty to notify and to obtain records from St. Mary's Medical Center, SunBridge Care and Rehabilitation and VA. Adequate notice was sent in June 2012, as discussed above. The Veteran's VA treatment records were obtained. The SunBridge facility went out of business, rendering any attempt to acquire records futile. The AMC did not obtain the St. Mary's records. The Board remanded again in January 2013 to obtain those records. As discussed, the appellant did not complete an authorized release form that would allow the records to be obtained. The Board finds that the RO complied substantially with April 2012 and January 2013 remand instructions. Further remand for additional development of the prior remand instructions is not warranted. See Stegall. Service Connection for the Cause of the Veteran's Death When a veteran dies of a service-connected disability, the veteran's surviving spouse is eligible for dependency and indemnity compensation. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. §§ 3.5(a), 3.312 (2012). The death of a veteran will be considered as having been due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a) (2012). In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by service caused or contributed substantially or materially to the veteran's death. The issue involved will be determined by the exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran. 38 C.F.R. § 3.312(a). Service connection may be established for the cause of a veteran's death when a service-connected disability "was either the principal or a contributory cause of death." 38 C.F.R. § 3.312(a); see 38 U.S.C.A. § 1310; see also 38 U.S.C.A. §§ 1110 and 1112 (setting forth criteria for establishing service connection). 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 contributory cause of death must be causally connected to the death and must have "contributed substantially or materially" to death, "combined to cause death," or "aided or lent assistance to the production of death." 38 C.F.R. § 3.312(c)(1). See generally Harvey v. Brown, 6 Vet. App. 390, 393 (1994). Therefore, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). The appellant has reported that she was trained and worked as a nurse. The appellant has not supported her statements with proof of her training or her employment as a nurse. Nurses have some medical expertise and may provide competent medical evidence in certain circumstances. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Resolving reasonable doubt in her favor, the Board will accept her statements as competent medical evidence. Analysis The appellant seeks service connection for the cause of the Veteran's death. She contends that the Veteran's service-connected dysentery contributed to his death in addition to the causes of death listed on his death certificate. The Board must address several threshold questions before turning to her contentions. First, the Board must consider whether the cause of death was service-connected. If not, then the Board must consider whether the cause of death could have been service-connected. If not, the then the Board must consider whether the Veteran's actually service-connected disability caused, contributed to the Veteran's death. The Certificate of Death states that the Veteran died on March [redacted], 2000, of Parkinson's disease and listed coronary artery disease as a condition contributing to death but not resulting in the immediate cause of death. The Veteran was not service-connected for Parkinson's disease or coronary artery disease during his life. He was only service-connected for dysentery, which was rated as 10 percent disabling at the time of his death. Service connection for the cause of the Veteran's death cannot be granted on the basis that his service-connected dysentery principally caused his death. 38 C.F.R. § 3.312. The appellant has not made any such allegation during the thirteen years since the Veteran's death. The evidence of record does not otherwise suggest that his dysentery directly caused his death. The death certificate did not list dysentery or any intestinal disorder among the causes of death. A July 2001 patient letter addressed to the appellant states that a doctor had reviewed the Veteran's medical record at VA and the 1997 St. Mary's Medical Center records and it was his opinion that the bowel problems and his bowel surgery were unlikely to be the cause of death. The Board notes that the July 2001 opinion was by the same doctor that provided the December 1999 through March 2000 care described below. The Board notes that the July 2001 opinion was not an opinion obtained under the auspices of 38 U.S.C.A. § 5103A(a); at present, case-law does not require that any VA opinion appearing in the record meet the burden of adequacy under that statute, only those obtained pursuant to the statute must be adequate. Cf. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (noting that an examination provided pursuant to 38 U.S.C.A. § 5103A(d) must be adequate); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 463 (2007) (noting that the duty to assist in providing medical examinations and opinions under 38 U.S.C.A. § 5103A(d) is conditional). Clarification of this opinion would not result in a reasonable possibility of substantiating the claim; a further opinion would not result in benefits flowing to the appellant. In light of the foregoing, the Board finds that the Veteran's service-connected dysentery was not a principal cause of his death. The Board turns to consider whether the causes of death could have been service-connected. 38 C.F.R. § 3.312. Both Parkinson's disease and coronary artery disease have other medical names. Parkinson's disease is also known as paralysis agitans. Dorland's Illustrated Medical Dictionary 547, 1397 (31st ed. 2007). Coronary artery disease is also known as arteriosclerotic heart disease. See 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). Paralysis agitans and arteriosclerosis are classified as "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as cancer, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. When the "chronic disease" standards are not met, service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The appellant does not contend, nor does the evidence of record suggest, that Parkinson's disease was present during service, continuously present since service, or manifest within one year of separation. The Veteran's service treatment records do not show complaint, treatment, diagnosis or even suspicion of a neurological disorder. His March 1946 separation from service physical examination report indicates a "normal" neurological diagnosis. As a result, service connection for Parkinson's disease as the cause of the Veteran's death as a "chronic disease" is not warranted. See Walker, 708 F.3d at 1337. The record is more complicated with regard to coronary artery disease. The Veteran's service treatment records do not show coronary artery disease. He was treated for German measles in April 1943, infectious mononucleosis and acute pharyngitis in January 1944, and acute amoebic dysentery in February 1945. He underwent a March 1946 separation from service physical examination. The report indicates that his cardiovascular system was "normal." The Veteran filed a claim for service connection for glandular fever in March 1946 which was denied in a March 1946 rating decision. The Veteran's glandular fever claim was reviewed again in an October 1949 rating decision. Infectious mononucleosis was not found on his separation examination and the denial of service connection was continued for glandular fever. Glandular fever is another name for infectious mononucleosis. Dorland's Illustrated Medical Dictionary 700 (31st ed. 2007). The Veteran filed a claim for service connection for heart problems secondary to "Dengue Fever" in May 1996. The record at that time included private treatment records dated in 1988 showing an acute myocardial infarction. The Veteran was seen in September 1988 for sudden onset severe left chest and shoulder pain. The intake note states that he had been on nitrates and a calcium channel blocker for a year or more because of angina-like chest pain, but had not had a prior infarct or any kind of cardiac study. A second note on the same date shows a previous history of a positive treadmill exercise test two years before and significant exertional angina on medication. The remaining records do not provide any greater detail on the Veteran's medical history. In light of the only two year medical history of cardiac problems without any lay evidence of heart problems earlier than that, the RO determined that there was no evidence to relate the Veteran's coronary artery disease to service. That claim was denied as not well grounded in a July 1996 rating decision. The appellant initiated her original claim for service connection for the cause of the Veteran's death with a July 2000 statement. She indicated that the Veteran had been hospitalized during service at Camp San Luis Obispo for mononucleosis and strep throat and again for "the tropical diseases dengue fever and amebic [sic] dysentery..." She did not allege that these conditions caused coronary artery disease or that his coronary artery disease was present in service, continuously present since service, manifest within one year of service separation or was in any way related to service. The appellant has submitted a copy of a March 1945 letter from the Veteran to her in which he reports that he was being treated for amoebic dysentery. There is no indication of dengue fever. Although the appellant is a competent medical expert, she was not in fact with the Veteran when he supposedly suffered from dengue fever and could not have personally observed him. The medical evidence from that time indicates a different disease, amoebic dysentery, without a second diagnosis. Moreover, the first mention of dengue fever was 51 years after the Veteran was supposedly infected. The Board finds that coronary artery disease was not present during service, continuously present since service, manifest within one year of separation from service, or is related to any incident of service. The Veteran's service treatment records do not show arteriosclerosis. His private medical records do not show a history of heart problems prior to approximately 1986, forty years after separation from service. There has been no allegation of symptoms during service, continuously since service or within one year of separation from service. No evidence explains, agrees with or even mentions the 1996 contention that the Veteran had a heart condition due to dengue fever. Even if dengue fever could cause coronary artery disease, the Veteran did not have dengue fever during service. The Board concludes that the Veteran's Parkinson's disease and coronary artery disease were not disabilities for which service connection could have been granted. Thus, service connection for the cause of the Veteran's death cannot be granted directly for these disabilities. 38 C.F.R. § 3.312. Service connection for the cause of the Veteran's death cannot be granted on the basis that his service-connected dysentery caused his Parkinson's disease or coronary artery disease. The appellant has not made any such allegation during the thirteen years since the Veteran's death. The evidence does not otherwise suggest that dysentery or any other intestinal disorder caused either Parkinson's disease or coronary artery disease. The Board turns to the last remaining theory of the case and the appellant's contentions that the service-connected disability contributed to the cause of the Veteran's death. The appellant's contentions are not that Parkinson's disease or coronary artery disease are directly related to service, but that the service-connected dysentery resulted in a 1997 surgery which removed much of the Veteran's large intestine. Lacking the intestine, the appellant argues that the Veteran became dehydrated which accelerated his death. She argues that many other people live a long time with Parkinson's disease. As stated, the appellant is a competent medical expert. The Board accepts her statements that his intestinal removal could result in dehydration and that dehydration could accelerate the progress of Parkinson's disease as medically plausible. The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Board must compare her opinion to the remaining evidence of record. The appellant appears to be conflating two episodes of care into a single series of events. In many statements, including April 2006, July 2007, November 2008 and June 2011, the appellant indicates that the Veteran had intestinal problems resulting in an emergency admittance to the VA hospital. The Veteran was ultimately transferred to St. Mary's Medical Center for intestinal surgery. The appellant claims that a surgical nurse told her that they removed "a whole bucketful of his intestines." The Veteran was then transferred back to VA for a lengthy hospitalization at the VA Medical Center (VAMC) in Walla Walla, Washington, for dysentery problems and was transferred to a nursing home where he died a week later. The treatment records diverge from her account. The Veteran was service-connected for dysentery with a 10 percent disability rating. In February 1997, the Veteran underwent a sigmoid colectomy with primary anastomosis for volvulus. The surgical note indicates that the sigmoid colon was resected. Anatomically, the colon is divided into four regions, the ascending, transverse, descending and sigmoid colon. Dorland's Illustrated Medical Dictionary 393 (31st ed. 2007). Contrary to the appellant's statements of "a whole bucketful of his intestines" having been removed, the surgical note does not describe involvement of more than the sigmoid colon. The VA treatment records indicate that he was admitted to the Walla Walla VAMC in July 1999. He had presented with a distended abdomen and was thought to have a bowel obstruction. The Veteran was transferred to the St. Mary's Medical Center for a colonoscopy. He was found to have no obstruction and had an ileus and pseudo-obstruction instead. The ileus and pseudo-obstruction were thought to be secondary to a urinary tract infection. This note states that the Veteran was extremely stuporous but gradually improved. He was transferred to the Seattle VAMC due to a series of attacks of chest pain. Extensive coronary artery occlusion was found by cardiac catheterization. He was felt not to be a candidate for surgery and was transferred back to Walla Walla. The final diagnosis regarding the chest pain was an acute myocardial infarction. The history shows that the Veteran did not recover his premorbid physical capacity despite physical therapy. An August 1999 VA examination report contains a description of the Veteran's recent medical history. The Veteran had been admitted to the Walla Walla VAMC in July 1999. He had presented with a distended abdomen and was thought to have a bowel obstruction. The Veteran was transferred to the Walla Walla General Hospital for a colonoscopy. The colonscopy ruled out a bowel obstruction and he was thought to have a paralytic ileum, which he had many times before. The Veteran had nausea and vomiting, but was treated and improved. On physical examination, his abdomen was full, non-tender, and moved with respiration. He had a scar in the infra-umbilical area from a previous surgery. The liver, spleen and kidneys were not palpable. Auscultation of the abdomen was done. Bowels sounds were noted to be present and within normal range. The Veteran was evaluated again at a December 1999 admission. He had Parkinson's dementia. He was found to have blood in his stool. He was sent to a local emergency room, before being transferred to the VAMC. He was shuttled between the VAMC and the Walla Walla General Hospital due to lethargy before eventually remaining at the VAMC. A CT scan had found an abnormality which a neurosurgeon eventually stated was cerebral atrophy and the brain settling to one side inside the skull. The Veteran had no symptoms to go along with his gastrointestinal bleeding and returned to his normal mental status. Following testing, the Veteran was determined to have an "upper GI bleed" which resolved. Preparations were made to transfer the Veteran to a nursing home, but he developed a fever and began vomiting before a transfer could be completed. He became lethargic again. A chest x-ray demonstrated a right infiltrate and effusion. He was diagnosed with pneumonia. He was treated and returned to his normal mental status. The Veteran was between VA and a private nursing home repeatedly in January, February, and March 2000. His VA treatment records show difficulty eating and drinking independently. The Veteran was incontinent of urine and bowel throughout this period. Despite many entries regarding bowel function, there were no notations of an ongoing bowel disorder in 2000. On the contrary, a January 27, 2000 note states that the Veteran was unable to take in enough food/drink to maintain his hydration and nutrition. A February 23, 2000 weekly assessment note indicates that the Veteran required assistance with feeding. His intake of food and fluids had improved. His bowels movements had been regular. A February 26, 2000 mental health nursing note shows that placement of an IV was discussed to ensure hydration after the Veteran was found slumped over his breakfast, unable to maintain his posture. He was placed on a thickened liquids diet. The Veteran was provided with occupational therapy to use modified utensils to feed himself. A March 2000 VA examination report describes his recent medical history one week prior to his death. Due to his Parkinson's disease, he was unable to provide a medical history. A nurse, who had worked with the Veteran off and on for four years, provided the history. When not in bed, the Veteran was seated in a wheelchair. He was able to stand to transfer out of the wheelchair with assistance. He was unable to walk independently. He was usually confused. His problem list included Parkinson's disease with debilitating dementia. He had incontinence of the bladder and bowel. His balance was poor and he was unable to ambulate. He was unable to perform self-care. He required assistance with feeding. He had previous difficulty swallowing. He has been suspected of having aspiration pneumonia. He required thickened liquids. He was at high risk of falling. Other medical problems included coronary artery disease with a past history of acute myocardial infarction, pseudo-obstruction of the bowels, past history of urinary tract infection, gastrointestinal bleeding and pneumonia recently resolved. On physical examination, the Veteran was drowsy. He fatigued quickly. His state of nutrition was good. His body build was frail and he weighed 115 pounds the previous month. The Veteran's abdomen had active bowel sounds, well heard in all quadrants. He had surgical scars. No hernias were evident. No masses or organomegaly were noted. The Veteran's mental status showed that he was alert at times, at other was quite drowsy. He fell asleep during part of the examination. By history, he was capable of some intelligible conversation, but was not communicative during the exam. The examiner stated that the Veteran's physical and mental limitations related to his Parkinson's disease with dementia appeared permanent. A July 2001 patient letter addressed to the appellant states that a doctor had reviewed the Veteran's medical record at VA and the 1997 St. Mary's Medical Center records and it was his opinion that the bowel problems and his bowel surgery were unlikely to be the cause of death. He attributed the Veteran's decline and death to his difficulty swallowing and worsening mental status brought on by his Parkinson's disease. The Board has provided this level of detail to show three things. First, although there are notations of dehydration in the months preceding death, his dehydration and declining nutrition were attributed solely to his inability to consume sufficient food and fluids to maintain his health. The identified source of his inability and disinterest in eating or drinking was his advanced dementia. This weighs heavily against the appellant's claim. Second, the Veteran's service-connected dysentery was not mentioned. The acute GI bleed was of the upper, not lower, GI tract. The upper GI tract is anatomically the duodenum and above, while the lower GI tract involves the small and large intestines. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 255, 258-79 (8th ed. 2006). His previous bowel surgery was noted, but he had active and intact bowel sounds. The absence of lower GI symptoms or disorders also weighs heavily against the appellant's claim. Third, the appellant's recollection of the events is faulty. The appellant portrays the 1997 surgery as occurring during the 1999 sequence of care. She also states that the Veteran had one lengthy hospitalization at the end of his life, first at VA, then at a nursing home, involving surgery and transfer between multiple hospitals. No surgery occurred in 1999 or 2000. He was shuttled from facility to facility. The events she describes did occur, but occurred in a different sequence. The Board finds that the preponderance of the evidence is against a finding that the Veteran's service-connected dysentery "contributed substantially or materially" to death, "combined to cause death," or "aided or lent assistance to the production of death." The Veteran's dysentery was quiescent during his final months. The medical records show numerous entries of good bowel function. He had an upper GI bleed, but this does not implicate the colon disability for which he was service-connected. The Veteran was becoming dehydrated and malnourished, but these were clearly and overwhelmingly attributed to his declining mental status both by contemporaneous treatment records and the 2001 medical opinion. The Board acknowledges the appellant's medical expertise, but in light of the contrary medical evidence and her own confusion regarding the sequence of events leading up to the Veteran's death, the Board can place little probative weight on her statements. Service connection for the cause of the Veteran's death is not warranted. See 38 C.F.R. § 3.312. In light of the foregoing, the Board has found the preponderance of the evidence against the appellant's claim on every possible theory of entitlement. As such, the Board finds that the preponderance of the evidence is against the appellant's claim for service connection for the cause of the Veteran's death. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs