Citation Nr: 18152462 Decision Date: 11/27/18 Archive Date: 11/23/18 DOCKET NO. 14-34 712 DATE: November 27, 2018 ORDER Entitlement to service connection for cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in January 2003. The Certificate of Death lists the immediate cause of death as cardiorespiratory failure due to metastatic cholangiocarcinoma; no other contributory causes were listed. 2. The disabilities that caused the Veteran’s death were not manifested during the Veteran’s military service or within one year of discharge; nor were they otherwise caused or aggravated by a disease or injury in active duty service, to include exposure to herbicides. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran’s death have not been met. 38 U.S.C. §§ 1110, 1131, 1310, 5107; 38 C.F.R. § 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1961 to December 1983, to include service in the Republic of Vietnam. The Veteran died in January 2003 and the appellant is his surviving spouse. In May 2017, the appellant testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. The Board previously remanded this case in April 2018 for further development. The Board finds that there has been substantial compliance with its prior remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for cause of the Veteran’s death The appellant is seeking service connection for the cause of the Veteran’s death. Specifically, the appellant alleges that the disability that caused the Veteran’s death was the result of liver flukes that the Veteran contracted while stationed in Vietnam or due to Agent Orange exposure. In support of her claim, she submitted internet articles and research indicating that liver flukes in Vietnam had been linked to adenocarcinoma. The Certificate of Death lists the immediate cause of death as cardiorespiratory failure due to metastatic cholangiocarcinoma. No other contributory causes were listed. The Veteran was not service-connected for any disability, to include the disorders listed on his Certificate of Death. Service connection for the cause of the Veteran’s death may be granted if a disability incurred in or aggravated by service was either the principle or a contributory cause of the Veteran’s death. 38 C.F.R. § 3.312(a). For a service-connected disability to be the principle cause of death it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. 38 C.F.R. § 3.312(b). For a service-connected disability to be a contributory cause of death it must have contributed substantially or materially, and combined to cause death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(c)(1). 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. “Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death.” 38 C.F.R. § 3.312(c)(3). Generally, minor service-connected disabilities, particularly those of a static nature, or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. 38 C.F.R. § 3.312(c)(2). “There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature.” 38 C.F.R. § 3.312(c)(4). Initially, the Board notes that the Veteran’s records show that he did serve in Vietnam and that he is presumed to have been exposed to herbicides. However, the Board notes that presumptive service connection is not warranted as the Veteran’s cancer is not a type subject to presumption. 38 U.S.C. § 1116; 38 C.F.R. 3.307 (a)(6), 3.309(e). However, the appellant can still establish service connection for disability due to Agent Orange exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). After considering the totality of the evidence, the Board finds that the preponderance of the evidence demonstrates that the disabilities that caused the Veteran’s death, cardiorespiratory failure due to metastatic cholangiocarcinoma, were not related to military service. Service treatment records are silent with respect to any findings associated with cholangiocarcinoma. Significantly, there is no medical evidence that these disorders manifested to a compensable degree within one year of the Veteran’s discharge so the service incurrence of such may not be presumed. Moreover, there is no competent lay or medical evidence linking these disorders to service. Importantly, the April 2018 VA examiner opined that the Veteran’s cholangiocarcinoma, which caused the Veteran’s death, was less likely as not caused by or a result of military service. The examiner observed that per oncology note, the Veteran had a history of colitis and possible sclerosing cholangitis, which is a risk factor for cholangiocarcinoma. The examiner noted that there was a likelihood of exposure to liver fluke, which has been conclusively linked to cholangiocarcinoma, while stationed in Vietnam. However, there was a lack of evidence showing any parasitic disease in the pathology report or service treatment records. However, the lack of diagnosis or prior treatment cannot rule out the possiblility of liver fluke infection as patients can remain asymptomatic for years. There is no test available to determine if liver fluke infection was the underlying cause of cholangiocarcinoma or other liver, bile duct or gallbladder conditions. The examiner continued that there was no data definitively linking Agent Orange exposure with cholangiocarcinoma, but that certain chemical exposures and inflammatory conditions have been linked to the development of this cancer, but there is no way to prove this link. The examiner concluded that although there may be the possibility of the Veteran being exposed to liver fluke infection in Vietnam, the presence of strong risk factor of ulcerative colitis, would first point to it as causative factor rather than unproved infection with liver flukes. Further, Agent Orange exposure is not considered associated with cholangiocarcinoma. After the VA opinion, the appellant submitted medical evidence that appears to indicate that the opinion is inadequate by showing that the Veteran did not have a confirmed diagnosis of ulcerative colitis. However, numerous other medical records clearly show that the Veteran was diagnosed with ulcerative colitis. Significantly, the VA examiner, who has been identified as a medical doctor, reviewed the record, clearly outlined the Veteran’s relevant medical history and cited to several medical sources in the opinion. Moreover, the examiner offered a detailed rationale for the opinion. The Board finds that the opinion is sufficient and of high probative value. See 38 C.F.R. § 3.159 (c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Moreover, the Board acknowledges that the appellant has submitted publications indicating a link between liver flukes and cholangiocarcinoma. In this regard, the Board notes that when medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion, a claimant may use such evidence to meet the requirement for a medical nexus. Wallin v. West, 11 Vet. App. 509 (1998). However, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise “is too general and inclusive.” Sacks v. West, 11 Vet. App. 314, 317 (1998) (a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). Still, medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor’s statements was “adequate to meet the threshold test of plausibility”). However, as discussed above, the VA examiner considered the entire claims file when forming their opinion concerning the Veteran’s cholangiocarcinoma and still found no such link to his service, but rather determined that his cholangiocarcinoma was due to ulcerative colitis. Moreover, given that these articles are general in nature and do not specifically address the Veteran’s disability, they have minimal probative value when weighed against the VA opinion that is specific to the Veteran’s case. In this regard, the examiner thoroughly considered the Veteran’s record and medical history when forming their opinion. The Board recognizes that the appellant believes that the Veteran died as a result of his service in Vietnam. However, the record does not reflect that the appellant has the necessary training or expertise to relate the cause of the Veteran’s death to service. A layperson is generally not capable of opining on matters requiring medical knowledge. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In sum, the appellant’s opinion as to cause of death is of little probative value and is outweighed by medical evidence of record.   While the Board sympathizes with the appellant’s loss, it must conclude that a preponderance of the evidence is against the claim for service connection for the cause of the Veteran’s death as there is no persuasive evidence linking the Veteran’s cause of death to any injury or disease during service, to include exposure to herbicide. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b). L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.N. Moats