Citation Nr: 21020872 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 14-44 382 DATE: April 8, 2021 ORDER Service connection for the cause of the Veteran’s death is granted. FINDINGS OF FACT 1. The Veteran died in December 2011 and his Certificate of Death reflects that the immediate cause of death was cardiac arrhythmia due to or a consequence of myocardial infarction, with respiratory failure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, pneumonia, anemia, hypertension, hypercholesteremia, diabetes mellitus, and bladder cancer listed as other significant conditions contributing to death, but not resulting in the underlying cause. 2. At the time of the Veteran’s death, service connection was in effect for enucleation with prosthesis of the right eye and psychoneurosis with hysteria. 3. Resolving all doubt in favor of the appellant, the Veteran’s service-connected psychoneurosis with hysteria contributed to the cause of his death. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran’s death have been met. 38 U.S.C. §§ 1110, 1310, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from July 1943 to February 1946. He died in December 2011 and the appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in March 2014 by a Department of Veterans Affairs (VA) Regional Office. In November 2017, the appellant and her son testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2018, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for the cause of the Veteran’s death. Service connection for the cause of a veteran’s death may be granted if a disability incurred in or aggravated by service was either the principal or contributory cause of the veteran’s death. 38 U.S.C. §§ 1110, 1310; 38 C.F.R. §§ 3.303, 3.312(a). For a service-connected disability to be the principal cause of death, it must singly or jointly with some other condition be the immediate or underlying cause of death, or be etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one not related to the principal cause. For a service-connected disability to be a contributory cause of death, it must have contributed substantially or materially; combined to cause death; aided or lent assistance to the production of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(c)(1). It is not sufficient to show that it causally 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 diseases or injuries primarily causing death. 38 C.F.R. § 3.312(c)(3). The Veteran died in December 2011 and his Certificate of Death reflects that the immediate cause of death was cardiac arrhythmia due to or a consequence of myocardial infarction, with respiratory failure, COPD, atrial fibrillation, pneumonia, anemia, hypertension, hypercholesteremia, diabetes mellitus, and bladder cancer listed as other significant conditions contributing to death, but not resulting in the underlying cause. At the time of his death, he was service-connected for enucleation with prosthesis of the right eye and psychoneurosis with hysteria, which had been in effect since April 1, 1946. The appellant argues that the Veteran’s psychoneurosis with hysteria contributed to the cause of his death on the basis that his cardiac conditions, to include cardiac arrhythmia, myocardial infarction, atrial fibrillation, and hypertension, developed as a result of the stress and anxiety associated with such longstanding psychiatric disorder. She further alleges that the Veteran did not adequately follow medical advice or seek care when appropriate due to his psychoneurosis with hysteria and, ultimately, such lack of care contributed to the cause of his death. As noted in the Board’s January 2018 Remand, the appellant submitted a letter dated in July 2013 from a private physician, Dr. J.W. Therein, Dr. J.W. noted the Veteran was diagnosed with COPD, atrial fibrillation, and loss of an eye and opined that, considering his constant medication, his anxiety and depression were related to such conditions. In addition, Dr. J.W. reported that anxiety and depression could exacerbate the conditions of atrial fibrillation and COPD. The appellant also submitted medical treatise articles in March 2014 that addressed the general relationship between anxiety and cardiac disorders; however, such are not specific to the Veteran. Subsequent to the Board’s Remand, the appellant submitted a June 2017 evaluation from a private psychologist, Dr. Q.A-S. In pertinent part, he opined it is more likely than not that the Veteran’s anxiety and depression “played a strong role in his refusal of medical care, as well as his self-neglect in regard[s] to his diabetes and need for oxygen supplementation”. Dr. Q.A-S. based his opinion on the statements of the appellant and supporting documentation throughout the Veteran’s treatment records demonstrating the anxiety, refusal, and fears of worsening health dating back to 1946. Although he determined it is more likely than not that the Veteran’s anxiety and depression played a primary role in his declination of mental health and medical care throughout his life, as well as his noncompliance with medical regimens prescribed, he stated it was outside the scope of his practice to determine medical causality related to the lack of usage of oxygen and medications. Specifically, Dr. Q.A-S. stated that he could not provide an opinion as to whether or not the Veteran’s repeated refusal to maintain his diabetes regime, use his oxygen, and/or take medications for his medical issues directly contributed to his death; rather, such opinion would need evaluation by a medical examiner or forensic pathologist. In June 2018, a VA physician, R.L., reviewed the record, to include the aforementioned evidence, and opined it is less likely than not that the Veteran’s service-connected psychoneurosis with hysteria contributed substantially or materially to the cause of his death, combined to cause death, or aided or lent assistance to the production of death. As rationale, Dr. R.L. reviewed the articles submitted for review and noted that the studies cited to therein were not conclusions of fact, and neither a link nor an association was a “cause.” Further, he found probative the medical records dated in December 2011 that showed the Veteran was not “gravely disabled due to a mental disorder,” did not have physical or mental impairments that increased the risk of harm to self or others, and had normal judgment, insight, memory, and mood, without delusions, hallucinations, or suicidal/homicidal ideations. Moreover, Dr. R.L. noted there was no supporting evidence or rationale provided in support of the favorable opinions of record. Furthermore, he stated that he was unaware of any evidence-based medical literature or general medical consensus, and could not find any such evidence in the medical records, that would provide evidence that the Veteran’s service-connected psychoneurosis with hysteria would have contributed substantially or materially to the conditions noted in the medical records as to the cause of his death, combined to cause death, or aided or lent assistance to the production of death. Conversely, another private physician, Dr. J.N., wrote in a July 2018 letter that “it is reasonable to say” that it is at least as likely as not that the Veteran’s service-connected generalized anxiety disorder (GAD) contributed to his heart attack. He explained that anxiety is associated with an outpouring of cortisol and adrenaline, which could put a significant strain on the heart. In addition, Dr. J.N. noted that the Harvard Health Letter of March 2012 reports that heart patients with GAD were shown to be more likely to experience heart attacks than those patients who do not have GAD. He also found pertinent that the Veteran’s Global Assessment Functioning scores were 55, which implied a significant impairment of judgment, thinking, and mood that, when combined with a significant level of anxiety, would be expected to be associated with significant impairment in several areas of life function. Dr. J.N. further noted the Veteran’s refusal to accept medical care, and stated that depression and anxiety were often related to discouragement and demoralization, which would as likely as not be expected to contribute to the refusal of medical care. In March 2019, the VA examiner who offered the June 2018 opinion, Dr. R.L., reviewed Dr. J.N.’s medical opinion, to include the Harvard Health Letter cited therein, and again opined that it is less likely than not that the Veteran’s service-connected psychoneurosis with hysteria contributed substantially or materially to the cause of his death, combined to cause death, or aided or lent assistance to the production of death. In this regard, he observed that his treatment records were silent for any evidence of any abnormally sustained elevated blood pressure readings and heart rate prior to, or at the time of, death, which would refute an elevated cortisol level. In this regard, Dr. R.L. cited the Veteran’s vital statistics from December 2011. He further indicated that there was no supporting objective evidence of any elevated cortisol levels as a result of the Veteran’s service-connected psychiatric disability that would have predisposed him to his fatal heart conditions. Upon review, the Board finds the evidence is at least in equipoise as to whether a disability of service origin was a contributory cause of the Veteran’s death. As noted in the Board’s January 2018 Remand, Dr. J.W. did not provide a rationale in support of the favorable opinion and, therefore, the Board cannot rely upon such to award service connection. Similarly, the Board finds the opinion provided by Dr. Q.A-S. is not entitled to probative weight as he notably limited his opinion to those issues within the scope of his professional experience, which did not extend to the question of causation between the Veteran’s refusal of care and his death. Conversely, the Board affords probative value to the opinions provided by Drs. R.L. and J.N., who are both competent medical professionals, considered the relevant facts and accepted medical principles, and provided rationales for their opinions. Nevertheless, the Board notes that Dr. R.L. appears to have focused primarily on the evidence dated at the time of the Veteran’s death, whereas Dr. J.N. extended the scope of his opinion to include consideration of the effects of the Veteran’s service-connected psychoneurosis with hysteria throughout his lifetime, to include the resulting impact on his cause of death. Consequently, the Board resolves all doubt in the appellant’s favor and finds that such service-connected disability contributed to the cause of his death. Thus, service connection for the cause of the Veteran’s death is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.