Citation Nr: 1322778 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 12-14 230 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1951 to July 1971. The appellant is the surviving spouse of the Veteran. This case comes before the Board of Veterans' Appeals (Board) on appeal of an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin which denied the appellant's claim. In March 2013, the Veteran presented sworn testimony at a Travel Board hearing which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims folder. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. 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 in October 2010; his death certificate lists the cause of death as cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. 2. The competent and probative evidence of record serves to link the Veteran's service-connected sleep apnea and hemorrhoids to his fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is warranted. 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The appellant seeks service connection for the cause of the Veteran's death. In the interest of clarity, the Board will address the pertinent law and regulations and their application to the facts and evidence. The Veterans Claims Assistance Act of 2000 The VCAA describes VA's duties to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As discussed in more detail below, sufficient evidence is of record to grant the appellant's claim of entitlement to service connection for cause of the Veteran's death. Thus, any errors in complying with the notice or assistance requirements with respect to that matter are moot. Factual Background and Analysis In this case, the appellant, who is the Veteran's surviving spouse, contends that the Veteran's service-connected disabilities, to include the medications he took for them, contributed to his death. Through the appellant's testimony, and the available emergency room records, the evidence demonstrates that on the day the Veteran died in October 2010, he was experiencing bright red rectal bleeding and went to Freeman Neosho Hospital for treatment. Once there, he had a large bowel movement, noted to contain a lot of blood and clots. It was noted that the Veteran was on Coumadin and Plavix. He was given several units of blood, and it was determined that he must be transferred to a different facility, as a surgeon was needed. The Veteran requested that he be transferred to St. John's Regional Medical Center where his cardiologist was located. Records from St. John's are limited to an initial consultation note due to the May 2011 tornado that leveled the facility. The examining physician, J.W., M.D., noted that the Veteran had chronic atrial fibrillation and was taking Coumadin. His past medical history and surgical history included coronary artery disease, status post percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting, COPD, sleep apnea, hyperlipidemia, prostate cancer, chronic atrial fibrillation, bradycardia with pacemaker placement, gastrointestinal bleeding, probable history of colon cancer. After examining the Veteran, Dr. J.W. assessed the Veteran with active gastrointestinal bleeding, which was probably a lower gastrointestinal bleeding, but could not totally exclude upper gastrointestinal etiology. The Veteran died at St. John's, at the age of 80. The Certificate of Death lists the cause of death as cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. No autopsy was performed. At the time of his death, service connection was in effect for the following disabilities: bronchoasthma with chronic obstructive pulmonary disease (COPD); obstructive sleep apnea, associated with bronchoasthma; osteoporosis of the lumbar and thoracic spines, associated with bronchoasthma; internal and external hemorrhoids; a bilateral hearing loss disability; tinnitus; post operative appendectomy scar; and residuals of a fractured left wrist. In order to establish service connection for the cause of a veteran's death, the medical evidence must show that disability which was incurred in or aggravated by service either caused or contributed substantially or materially to cause death. See 38 U.S.C.A. § 1310 (West 2002); 38 C.F.R. § 3.312 (2012). 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 issue involved will be determined by 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, including, particularly, autopsy reports. See 38 C.F.R. § 3.312(a) (2012). 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. See 38 C.F.R. § 3.312(b) (2012). 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; that it combined to cause death; 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 it must be shown that there was a causal connection. See 38 C.F.R. § 3.312(c)(1) (2012); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). In order for service connection for the cause of a veteran's death to be granted, three elements must be present: (1) evidence of death; (2) evidence of in-service incurrence of disease or injury and/or service-connected disability; and (3) nexus evidence linking (1) and (2). Cf. Hickson v. West, 12 Vet. App. 247, 253 (1999). In this case, element (1) has obviously been met. With respect to element (2), as noted above, the Veteran was service-connected for obstructive sleep apnea associated with bronchoasthma as well as hemorrhoids at the time of his death. With respect to element (3), nexus, for reasons expressed immediately below, the Board finds that the medical evidence in this case shows that there existed a contributory relationship between the Veteran's service-connected sleep apnea and hemorrhoids and his fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding, and that service connection is therefore warranted. In April 2013, due to the complexities of the medical issues involved, the Board, pursuant to 38 C.F.R. § 20.901 (2012), requested a VHA opinion from a cardiologist to address whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's service-connected disabilities (to include sleep apnea and hemorrhoids) contributed to his fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia, and intestinal bleeding. In response to the VHA opinion request, the VHA reviewer, R.N., M.D., concluded that it is as likely as not that the Veteran's service-connected disabilities (to include sleep apnea and hemorrhoids) contributed to the Veteran's fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. Dr. R.N.'s rationale for his conclusion was based on his finding that obstructive sleep apnea is now well documented as a cause of hypertension, coronary artery disease, and advanced COPD and cor pulmonale as indicated in the Veteran's treatment records. Additionally, Dr. R.N. noted that the massive amounts of blood loss arising from the Veteran's hemorrhoids and augmented by the presence of three anticoagulants resulted in the already jeopardized heart and lung condition leading to death. He further reported that the treatment records documented right heart enlargement on echocardiogram and a fall in oxygenation due to blood and volume loss. The treatment records also indicated possible colonic lesions as a result of the hemorrhoids, and that use of oral and inhaled steroids for the Veteran's lung condition have been known to cause upper gastrointestinal ulcers. He also noted the massive, uncontrollable bleeding from the hemorrhoids and anticoagulants which caused the Veteran's death. The Board adds that T.G., R.N. similarly opined in a June 2011 letter that the Veteran died from a heart condition that "can be directly contributed to his service-connected disabilities of central obstructive sleep apnea, osteoporosis with multiple compression fractures, and bronchoasthma with COPD." T.G. further noted that "as a result of these disabilities, he suffered from right-sided cardiomegaly, ventricular hypertrophy, coronary artery disease with blockage, severe mitral valve regurgitation, pulmonary hypertension, congestive heart failure, atrial fibrillation, intermittent claudication, varicose veins, pulmonary fibrosis, kyphoscoliosis, pulmonary vascular disease, pedal edema, and cardiac block requiring a permanent pace maker and cor pulmonale." T.G. also opined that the Veteran died from side effects of drugs to include anticoagulant therapy targeted to prevent a heart attack or stroke, and steroids that could precipitate a gastrointestinal ulcer and bleeding. Finally, T.G. noted that severely decreased diminished pulmonary function, in addition to anatomical changes from compression fractures, kyphoscoliosis, and being barrel-chested, in addition to flattened diaphragm, were "all attributed to decreased cardiac function and subsequent multiple cardiac dysfunctions and disease." The reports of Dr. R.N. and T.G. appear to have been based upon thorough and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. The Board also notes that Y.M., M.D., opined in a letter dated May 2012 that the Veteran had moderate obstructive sleep apnea, and that the Veteran may have had increased risk of cardiovascular problems such as difficulty controlling hypertension, heart attacks, and abnormal heart rhythms. He further reported that excessive daytime sleepiness and difficulty concentrating may lead to an increased risk of error in daily activities. In contrast to the opinions discussed above, in April 2012, a VA examiner reviewed the file and noted the cause of death on the death certificate, observing that the Veteran's death was due to an intestinal bleed, which resulted in acute blood loss, anemia, resulting in hemorrhagic shock and then cardiopulmonary arrest. He thereafter concluded that the Veteran's service-connected disabilities did not contribute to his fatal intestinal bleed. However, the VA reviewer failed to provide an adequate rationale for his conclusion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. On the contrary, as discussed above, Dr. R.N. and T.G. specifically discussed the medical treatment records documenting the massive blood loss caused by the Veteran's hemorrhoids and use of anticoagulants which they opined caused his fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. Notably, there is no discussion of these factors in the April 2012 VA opinion. Accordingly, the Board finds the April 2012 VA opinion to be of no probative value in determining whether the Veteran's hemorrhoids and sleep apnea as well as the use of anticoagulants caused his fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding. In light of the foregoing, the Board concludes that the weight of the competent medical evidence of record indicates the Veteran's fatal cardiopulmonary arrest, hemorrhagic shock, acute blood loss, anemia and intestinal bleeding is related to his service-connected sleep apnea and hemorrhoids. Element (3), nexus, has accordingly been satisfied. In summary, for reasons and bases expressed above, the Board concludes that service connection for the cause of the Veteran's death is warranted. The benefit sought on appeal is granted. ORDER Service connection for the cause of the Veteran's death is granted. ____________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs