Citation Nr: 21012790 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 15-38 997A DATE: March 5, 2021 ORDER Service connection for the cause of the Veteran’s death is denied. FINDING OF FACT The Veteran died of multisystem organ failure due to septic shock due to possible bowel ischemia due to diabetes with metastatic prostate cancer listed as a significant condition contributing to death that is not etiologically related to service. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran’s death have not been met. 38 U.S.C. §§ 1310, 5107(b); 38 C.F.R. §§ 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Army from February 1963 to February 1966. He died in 2014. The Appellant is the Veteran’s surviving spouse This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The claim was remanded by the Board in September 2018, February 2019, and June 2020 for further development. The Appellant has not raised any issues with the duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board … to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Veteran’s death certificate shows that he died in August 2014 as a result of multisystem organ failure due to septic shock due to possible bowel ischemia due to diabetes with metastatic prostate cancer listed as a significant condition contributing to death. At the time of his death, the Veteran was service connected for residuals of cold injury, left lower extremity; residuals of cold injury, right lower extremity; and peripheral vascular disease, right lower extremity associated with residuals of cold injury, right lower extremity. The Appellant asserts that the Veteran’s death was due to his service connected disabilities preventing him from receiving chemotherapy treatment for his prostate cancer, or in the alternative, that the Veteran’s peripheral vascular disease contributed to the ischemia that led to septic shock by causing a decrease in the flow of blood to the Veteran’s heart. To establish service connection for the cause of a veteran’s death, the evidence must show that a disability, incurred in or aggravated by service, either caused or contributed substantially or materially to death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. VA has obtained multiple medical opinions on whether the Veteran’s service-connected disabilities either caused or contributed substantially or materially to the Veteran’s death. The first opinion was obtained in August 2015. The physician opined that it was less likely than not that the Veteran’s peripheral vascular disease contributed to his death. Their opinion was based on the Veteran’s peripheral vascular disease not being clearly nor consistently identified in the Veteran’s hospitalization records as an important factor in his clinical deterioration. The physician also opined that it was less likely than not that the Veteran’s cause of death was secondary to his service-connected peripheral vascular disease. Their rationale was based on the Veteran’s multisystem organ failure was not noted to be attributable to unilateral lower extremity peripheral vascular disease. Lastly, the physician opined that it was less likely than not that the Veteran’s peripheral vascular disease aggravated his cause of death. Their rationale was based on the Veteran’s peripheral vascular disease not being cited as a health concern or issue in the Veteran’s progress notes proximal to his death. The physician is competent to provide these opinions, the Board finds them to be credible, and affords the opinions great probative weight. After remand, another opinion was obtained in October 2018. This physician opined that it was less likely than not that the Veteran’s death was caused by an in-service injury, event, or disease. Their rationale was based on their being no evidence of an in-service injury, event, or disease, that would cause the Veteran’s multisystem organ failure, septic shock, possible bowel ischemia, diabetes, or metastatic prostate cancer. The physician also opined that it was less likely than not that the Veteran’s service-connected disabilities were a principle or contributory cause of his death. Their rationale was based on their being no delay, interruption, or prevention of care for the Veteran’s prostate cancer due to the Veteran’s service-connected cold injury residuals. The physician noted that the Veteran had prompt care for his prostate cancer in the form of surgery followed by radiotherapy and combined androgen blockade with gonadotropin-releasing hormone agonists and anti-agonists, but his prostate specific antigen (PSA) levels continued to elevate. The physician also noted that the Veteran underwent orchiectomy rather than Docetaxel treatment due to his peripheral neuropathy and was instead treated with secondary hormonal manipulation with abiraterone and prednisone. The physician concluded their rationale by finding that though there is evidence of Docetaxel not being chosen due to a potential of increasing the Veteran’s peripheral neuropathy, there is insufficient evidence that the alternative treatment contributed substantially or materially to the Veteran’s death as current evidence does not find a survival difference between Docetaxel and abiraterone as the risk of infection is present with both and would also have been significant with Docetaxel due to myelosuppression. The physician is competent to provide this opinion, the Board finds them to be competent, and affords the opinion great probative weight. In January 2020, after another remand, VA attempted to obtain another opinion, but a rationale was not provided due to mere speculation. This opinion is not adequate and will not be relied on by the Board. An opinion was obtained in March 2020. The VA examiner first opined that it was less likely than not that the Veteran’s prostate cancer treatment was delayed, interrupted, or prevented by the Veteran’s service-connected peripheral vascular disease. The examiner’s rationale was based on the Veteran receiving treatment with Docetaxel, but that treatment was discontinued when the Veteran exhibited increased discomfort from neuropathy. The examiner also found that the Veteran received alternative treatment for his prostate cancer besides Docetaxel, that unfortunately the cancer was resistant to and that it is not possible without mere speculation to state whether the Veteran would have had a more positive prognosis if he had been able to receive chemotherapy as treatment. The examiner also opined that it was less likely than not that peripheral vascular disease contributed to the fatality of the Veteran’s septic shock. They found that it was not possible to provide without mere speculation to determine if peripheral vascular disease contributed to the onset or the fatality of the Veteran’s sepsis as medical research is not available to support or repudiate the claim. The examiner explained that current medical research shows that veins and arteries dilate during septic shock and peripheral vascular disease can lead to blockages within the vascular system, but not all blockages will be complete and may never require medical intervention. They also noted that the Veteran had doppler showing right lower extremity abnormalities in 2009 and in 2013 he had a doppler that demonstrated normal compressibility and flow without filling defect in bilateral lower extremities. The examiner is competent to provide this opinion, the Board finds them to be credible, and affords this opinion great probative weight. In August 2020, another VA opinion was obtained. The physician opined that it was less likely than not that the Veteran’s peripheral vascular disease and/or residuals of a cold injury of the bilateral lower extremities contributed substantially or materially to the Veteran’s death; combined with another disease to cause the Veteran’s death; or aided or lent assistance to the Veteran’s death. The physician also opined that it was less likely than not that the Veteran’s cause of death was causally or etiologically related to service. The physician’s rationale was based on the Veteran having died of multisystem organ failure and was noted to have prostate cancer with bony metastasis and recurring UTIs. The physician noted that prostate cancer is a condition most likely caused by a gene mutation and that it was at least as likely that the urinary tract infection along with the immunocompromised state of the Veteran was material to the decline in the Veteran’s health ultimately leading to his death. The physician acknowledged that the Veteran had peripheral neuropathy and peripheral vascular disease due to cold injury, but found that it was less likely that the pathophysiology of the peripheral neuro-vascular disease had an impact in the eventual death of the Veteran. The physician is competent to provide this opinion, the Board finds them to be competent, and affords the opinion great probative weight. The Board finds that the Veteran’s death was not related to his service. Multiple medical opinions have been obtained to address the Appellant’s contentions and none could find any relation between the Veteran’s service or his service-connected disabilities with his death. The Board has found these opinions to be adequate and has afforded them all great probative weight. The Board acknowledges the Appellant’s argument that the Veteran’s treatment for prostate cancer was delayed due to his neuropathy. However, this contention was opined on by a physician that did not find the medical evidence to support this. The Veteran did receive treatment for his prostate cancer, and the treatment that the Appellant asserts could have prevented his death, Docetaxel, was attempted in July 2014 despite a February 2013 pharmacy consult finding that the Veteran was not a candidate for Docetaxel. However, the Docetaxel was discontinued when the Veteran had worsening of his peripheral neuropathy, which was a concern when it was determined that the Veteran was not a candidate for Docetaxel. As was noted in the October 2018 opinion, the Veteran’s PSA levels continued to rise despite treatment from surgery and combined androgen blockade, and Docetaxel also had a risk of infection that was present in treatment with abiraterone. Accordingly, the Board cannot find that the Veteran’s prostate cancer treatment was delayed due to the Veteran’s neuropathy. The Board also acknowledges the Appellant’s argument that the Veteran’s peripheral vascular disease contributed to his death. The Appellant has not shown that she has the requisite medical knowledge to provide a medical nexus opinion for his current disability. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board affords the Appellant’s lay statement less probative weight and affords more probative weight to VA medical opinions that did not find the Veteran’s peripheral vascular disease to contribute to his death. The Board concludes that there is no basis to establish a link between the Veteran’s death from multisystem organ failure and service or the Veteran’s service-connected disabilities. Accordingly, the preponderance of the evidence is against the claim. Because the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As such, service connection for the cause of the Veteran’s death is denied. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael Chandeck, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.