Citation Nr: 18155266 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 16-35 968A DATE: December 4, 2018 ORDER Entitlement to service connection for the Veteran's cause of death is granted. FINDINGS OF FACT 1. The Veteran died in August 2013. 2. Service-connected coronary artery disease contributed to death. CONCLUSION OF LAW A disease incurred in service contributed to death. 38 U.S.C. §§ 1310, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from May 1968 to September 1969. He died in August 2013. The appellant claims as a surviving spouse. 1. Entitlement to service connection for the Veteran's cause of death To establish service connection for the cause of a Veteran’s death, the evidence must show that a disability incurred or aggravated in service either caused or contributed substantially or materially to cause death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, 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. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. 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. Where the service-connected disability affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 38 C.F.R. § 3.312 (c)(3). The Veteran died on August [redacted], 2013. The death certificate lists cardio-pulmonary failure and metastatic gastric esophageal junction adenocarcinoma to the liver and peritoneum as causes of death. Generally, to establish service connection the appellant must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). At the time of his death, the Veteran was service-connected for coronary artery disease (CAD), bilateral hearing loss, diabetes mellitus type II, tinnitus, residuals of shell fragment wound to the left knee, and left knee scar associated with residuals of shell fragment wound to the left knee. The appellant asserts that the Veteran’s CAD caused his cardio-pulmonary failure. She also asserts that his metastatic gastric esophageal junction adenocarcinoma to the liver and peritoneum was the result of exposure to Agent Orange. Service connection for stomach cancer and prostate cancer were denied by the RO in a July 2013 rating decision. A medical opinion regarding the Veteran’s cause of death was obtained by the VA in February 2014. The opinion stated that the Veteran’s CAD less likely than not caused or substantially contributed to the Veteran’s death. The stated rationale was that the immediate cause of death of cardiopulmonary failure did not imply an ischemic even from CAD but rather terminal cardiopulmonary collapse, the common final event in terminal cancer patients. No further rationale was provided. Another VA opinion was obtained in August 2016. The opinion stated that the Veteran’s service-connected conditions less likely than not contributed to his death. The stated rationale was that the Veteran clearly died of natural progression of his terminal gastric cancer with metastatic disease. The examiner noted that although congestive heart failure (CHF) was listed as a contributing condition on the death certificate, there was no record of CHF prior to death and there was no evidence of myocardial infarction or ischemic cardiomyopathy conditions which could have caused CHF secondary to CAD. In March 2018 the appellant submitted an opinion from a private physician stating that the Veteran’s CAD was a major contributory causal factor to his cardiopulmonary failure. The opinion also stated that the Veteran’s adenocarcinoma was primarily due to Agent Orange exposure. To support these conclusions the physician stated that when cardiopulmonary failure occurs, it is usually due to ischemia, even when there is no identifiable infarction. Further, whether or not an infarction or ischemic signs or symptoms were present, the manner of death alone renders it statistically more likely than not that the cause of cardiovascular collapse was ischemic. As the Veteran had CAD, that makes it more likely than not that CAD was a major contributory cause. The Board finds that the most probative evidence weighs in favor of a finding that the Veteran’s service-connected CAD substantially contributed to his cause of death. While the two VA opinions indicated that CAD was less likely than not a substantial contributing factor, the opinion submitted by the appellant more thoroughly addressed the Veteran’s medical history and provided a more substantial rationale. Providing the benefit of the doubt, the Board finds in favor of the appellant. Service connection for cause of death is granted. In reaching this determination, we note that the Veteran received the Purple Heart, a commendation medal with “V” device and the CIB. Service connected disabilities included the residuals of the wound, coronary artery disease and diabetes mellitus. ] H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Creegan, Associate Counsel