Citation Nr: 21022429 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 12-17 588 DATE: April 15, 2021 REMANDED Entitlement to service connection for cause of the Veteran's death is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1943 to October 1945. He died in November 2008. The Appellant claims as the surviving spouse of the Veteran. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded the claim in December 2017 and May 2020. For the reasons addressed below, the Board finds an additional remand is necessary. See Stegall v. West, 11 Vet. App. at 268 (1998). Service connection for cause of the Veteran's death is remanded. The Appellant seeks service connection for the cause of the Veteran's death. In May 2017, the Board remanded the claim for an opinion on the etiology of the Veteran’s cause of death. After review of the record including the medical opinion that resulted from the first Board remand, an additional remand was necessary to allow the Board to make a fully informed decision. In March 2019, an opinion was obtained where the VA physician opined the Veteran’s service-connected PTSD was not a substantial or material contributory factor in the Veteran’s death. The rationale provided was that there was no evidence of record or established medical literature to support the contention that the Veteran’s PTSD was a substantial or material contributory factor causing the Veteran’s death. The Board noted in its May 2020 remand that the Appellant submitted treatise evidence on the relationship between PTSD, metabolic acidosis, and renal failure. The Board remanded a second time and another opinion was had later in May 2020 to address the treatise evidence. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Unfortunately, another remand is needed, because the resulting May 2020 opinion also failed to consider and discuss the submitted treatise evidence. In addition, the Appellant remarked through her July 2020 appellate brief in response to the VA’s June 2020 supplemental statement of the case (SSOC), that her theory of the cause of the Veteran’s death was not fully addressed by the opinion. The May 2020 examiner addressed a theory that the Veteran died because his service-connected PTSD caused a lack of appetite that led to such weight loss which resulted in severe dehydration causing renal failure and metabolic acidosis and death. The examiner concluded that that did not happen because the Appellant and the record did not establish severe dehydration. The examiner concluded that, “…the service-connected PTSD is less likely than not singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto.” Significantly, the Veteran’s last hospital admission notes saying, “It is likely that his acute renal failure is due to significant dehydration.” In light of this, if the examiner does not believe the Veteran’s PTSD caused lack of appetite that led to weight loss which resulted in dehydration causing acute renal failure, what does the examiner believe caused the dehydration that resulted in the Veteran’s acute renal failure, or why does he not believe it? The Appellant’s representative in a July 2020 response to the SSOC which relied on the May 2020 VA medical opinion, expressed a belief that the Appellant’s second theory of causation remained unaddressed, stating that the May 2020 reviewer utilized the wrong standard to address this second theory. The examiner opined that the cause of death was not related to the Veteran’s service-connected PTSD (primary cause/etiologically related), but never considered whether PTSD affected his will to live or his ability to rehab or to comply with medical instructions/advice (contributory cause) as claimed by the Veteran’s widow at the November 2016 hearing. The Appellant’s alternative theory expressed at the Board hearing is that PTSD during his last year before his passing, caused him to give up on life and he did not have the will to live, which they argue contributed to his death. “PTSD caused depression, which made it hard to get him to eat even before, but it was worse that last year,” according to Appellant’s testimony during the hearing. The matters are REMANDED for the following action: 1. Obtain an addendum VA opinion from the same medical doctor who provided the May 2020 report or another qualified medical person with experience with PTSD patients to determine whether the Veteran's death was caused by a service-connected disability or disabilities. The record must be made available to the examiner and the examiner should indicate in his/her report whether the claims file was reviewed. Specifically, the examiner should read the Appellant’s March 2018 article on the relationship between PTSD, metabolic acidosis and renal failure, the August 2018 Norwood hospital report of the Veteran’s stay that ended in his death, and the November 2016 Board hearing transcript. The examiner should provide an opinion as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability), that the service-connected PTSD singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. (b.) If the above opinion is negative, then the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that PTSD contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death or the disabilities which ultimately resulted in the Veteran's death. The examiner must comment on the March 2018 article submission from the Appellant that looks at the relationship between PTSD, metabolic acidosis, and renal failure and the Appellant’s November 2016 Board hearing testimony. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Black, 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.