Citation Nr: 9816069 Decision Date: 05/26/98 Archive Date: 06/03/98 DOCKET NO. 96-12 791 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for the cause of the veteran’s death. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Mark E. Goodson INTRODUCTION The veteran served on active duty from February 1941 to January 1945. He also had prior reserve service. The veteran died on January [redacted], 1995. The appellant is his widow. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 1995 decision by the RO that denied the appellant’s claim of entitlement to service connection for the cause of the veteran’s death. CONTENTIONS OF APPELLANT ON APPEAL The appellant and her representative contend that the veteran’s service-connected anxiety disorder was either a cause or a contributing factor in the veteran’s death. The representative requests application of the benefit-of-the- doubt doctrine to the appellant’s claim. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the appellant’s claim of entitlement to service connection for the cause of the veteran’s death. FINDINGS OF FACT 1. The cause of the veteran’s death was a ruptured abdominal aortic aneurysm. Coronary artery disease was a significant condition contributing to his death. 2. At the time of his death, service connection was in effect for an anxiety reaction, rated as 50 percent disabling. 3. The abdominal aortic aneurysm and coronary artery disease began many years after service and neither condition was caused or made worse by service-connected disability. 4. The service-connected anxiety disorder did not substantially or materially contribute to the veteran’s death. CONCLUSION OF LAW Service connection for cause of the veteran’s death is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1310, 5107, 7014 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran’s service medical records reflect that, on entrance and separation examinations conducted in November 1937 and February 1939, his cardiovascular system, kidneys, and neuropsychiatric condition were found to be normal. On a February 1941 entrance examination, his cardiovascular system, endocrine system, and blood sugar were all found to be normal. A July 1944 clinical record reflects that, in June 1944, the veteran was injured as the result of an explosion. He was noted to have been unconscious for eight hours thereafter. He complained of, inter alia, being nervous and shaky. On examination, his heart was found to be normal, and his blood pressure was 126/78. Examination of his vascular system revealed a pulse of good quality at 80 beats per minute. The diagnosis was psychoneurosis, mixed (hysteria and anxiety state), moderate. During the remainder of the veteran’s active military service, he was hospitalized almost continuously for treatment of residuals of the explosion. A September 1944 clinical record brief reflects that his arteries were found to be normal, his blood pressure was 110/70, and his heart was found not to be enlarged, although P2 was noted as greater than A2. The diagnosis was a moderately severe cerebral concussion, and a secondary anxiety-hysteria psychoneurosis. A December 1944 final summary reflects that physical and neurological examinations revealed no abnormalities, and that x-ray of the chest was within normal limits. The diagnoses were psychoneurosis, conversion hysteria, and cerebral concussion. An October 1945 VA examination report reflects the veteran’s complaints of headaches, burning eyes, nervousness, combat dreams, weight loss, annoyance with noise and argument, and ringing in his ears. On physical examination, his blood pressure was found to be 115/80. His cardiovascular system and kidneys were found to be normal. The pertinent diagnosis was post-concussion syndrome with psychoneurotic admixtures. An August 1973 VA outpatient treatment record reflects the veteran’s statement that he was hospitalized in July 1973 with a question of a myocardial infarction. He was noted to be tense, anxious, and tearful. There was no diagnosis. A January 1974 VA Hospitalization summary reflects the veteran’s complaints on admission of chest pain of six months’ duration. He was noted to have had an electrocardiogram (EKG) in September 1973 which showed multiple premature ventricular contractions (PVC’s) and nonspecific sinus tachycardia changes. Physical examination revealed no significant abnormality. A chest x-ray was normal. EKG revealed multiple PVC’s, but was otherwise normal. He exhibited some angina during his hospital stay. After 18 days of hospitalization, he was discharged with diagnoses of arteriosclerotic heart disease (ASHD), angina pectoris, and multiple PVC’s with normal sinus rhythm, class II. A December 1975 private medical record of Paul C. Balze, M.D., reflects diagnoses of anxiety neurosis and ASHD. Dr. Balze opined that the combination of the two medical problems rendered the veteran unemployable. However, he did not link the two conditions etiologically. Additional VA treatment records dated from February 1974 to February 1980 reflect the veteran’s complaints of headaches, dizziness, nervousness, and chest pains, as well as diagnoses of psychiatric and heart disorders. However, none of these records reflect any medical opinion which causally linked any heart or vascular disorder to the veteran’s service-connected psychiatric disorder. A March 1980 VA examination report reflects the veteran’s complaints of headaches, insomnia, depression, and chest pain. The examiner noted the veteran’s history of intermittent episodes of chest pain, and his hospitalizations therefor. The examiner noted that none of the hospitalizations resulted in finding of damage to the heart; only PVC’s were found on one occasion. The veteran’s emotional condition was found to be manifested by headaches and insomnia. Under the section of the report for “other tests recommended,” the examiner queried “[i]s stress test indicated?” below which the examiner noted “possibly the chest pain is an anxiety equivalent as opposed to secondary to a heart condition.” The examiner recommended that the veteran be seen by a cardiac specialist to see if the chest pain was secondary to emotions only. The diagnosis was anxiety neurosis, moderately severe. VA outpatient treatment records dated from February 1991 to October 1992 reflect the veteran’s complaints of, inter alia, chest pain, headaches, and a July 1991 fall. Of these records, a May 1991 outpatient report reflects that the veteran had discontinued smoking two years previously and was exposed to much second hand smoke. A December 1991 record noted a history of diabetes mellitus. However, these records contained no medical opinion which causally linked any heart or vascular disorder to the veteran’s service-connected psychiatric disorder. An October 1992 VA x-ray report reflects that examination of the veteran’s chest compared with previous films from February 1990 revealed that the heart was not enlarged and that there was no dilation or decompensation. Mild uncoiling of the ascending thoracic aorta was noted. The diagnostic impression was that the cardiac silhouette was normal. Records from the VA outpatient clinic in Allentown, Pennsylvania (VA Allentown Clinic), dated from 1972 to January 1995, reflect the veteran’s complaints of, inter alia, headaches, diabetes, and chronic obstructive pulmonary disease (COPD). However, none of these records contain a medical opinion which causally links any heart or vascular disorder to the veteran’s service-connected psychiatric disorder. The VA Allentown Clinic records included an April 1993 report, which reflects that the veteran complained of discomfort in his right lower rib cage, increasing on deep inspiration. Physical examination of his abdomen revealed minimal discomfort in the upper right quarter on palpation. X-ray studies of the right ribs, conducted later that month, revealed no fracture or other recent bone injury, or trauma to the underlying lung parenchyma. The heart and mediastinal structures were found to be normal. There was no diagnosis. The VA Allentown Clinic records also included a September 30, 1994, record reflecting complaints of chest pains and diagnoses of COPD, diabetes mellitus, trouble sleeping, and neurosis. They also reflect January 1995 treatment for a possible abdominal aortic aneurysm and his referral to Lehigh Valley Hospital (LVH). However, none of the VA Allentown Clinic records reflect any medical evidence of a causal link between the veteran’s service-connected anxiety disorder and any vascular or cardiovascular disorder. January 1995 private medical records from LVH reflect that on January 12, 1995, the veteran was admitted with complaints of a two-week history of back and abdominal pains, constipation, weight loss, and decreased appetite. Ultrasound testing revealed a small focal intrarenal abdominal aortic aneurysm. The initial assessment was abdominal back pain of unknown etiology; an abdominal aortic aneurysm, not ruptured and “previously not a source of symptoms;” diabetes mellitus; and COPD. A final summary reflects that his history was significant for COPD, angina, anxiety disorder, headaches, peptic ulcer disease, and diabetes mellitus. A cytoscopy was planned for January 19, 1995, but that night the veteran’s back pain got worse, and in the early morning of January 19, he “coded.” An emergency surgical repair of the ruptured abdominal aortic aneurysm was then undertaken, but the veteran developed a coagulopathy. Unfortunately, on January [redacted], 1995, during a surgical procedure for abdominal compartmental syndrome, the veteran died. The final diagnoses were ruptured abdominal aortic aneurysm, COPD, coronary artery disease, diabetes mellitus, and urinary retention. The certificate of death reflects that the immediate cause of the veteran’s death was a ruptured abdominal aortic aneurysm. Lines on the certificate provided for the certifier to list conditions, “if any,” leading to the immediate cause of death, including disease or injury that initiated events resulting in death, were left blank. The certificate reflected that other significant conditions contributing to death, “but not resulting in the underlying cause” (i.e., the abdominal aortic aneurysm), was coronary artery disease. Other lines on the certificate for additional contributing conditions were left blank. The certificate reflects that no autopsy was performed, and that the manner of death was natural. The certifier was Thomas Brandecker, M.D. An August 1995 letter from Dr. Brandecker to the veteran’s representative reflects that the appellant had provided him with papers to review, dated from 1955 and the 1970’s, regarding the veteran’s condition. Dr. Brandecker reported that these papers stated that the veteran had a neurosis and anxiety disorder as well as an early diagnosis of coronary artery disease. Dr. Brandecker opined that, [a]lthough it is difficult to draw a definite causality between the two conditions, it is conceivable that anxiety and neurosis could in some way contribute to the development of an aneurysm. It is also possible that condition could affect the patient’s ability to seek medical attention quickly and then accurately describe his symptoms. In an August 1996 letter from the RO to Dr. Brandecker, the RO asked Dr. Brandecker to identify the treatises or other basis he used to indicate that an aneurysm could be secondary to a neuropsychological condition, and to indicate any clinical evidence upon which he relied to show that his hypothesis was demonstrated in the veteran’s case. In response, Dr. Brandecker’s August 1996 letter to the RO reflects that he could provide “no definite data or evidence” to prove that anxiety or neurosis caused the veteran’s aneurysm. Dr. Brandecker said that, since those conditions have been shown to increase the rate of myocardial infarction and to contribute to cerebrovascular disease, it was plausible that this could “in some way” contribute to the development or perhaps the rupture of an aneurysm. A September 1996 letter from a VA physician reflects that he reviewed the claims file, including the etiological opinion of Dr. Brandecker, and opined that there was no medical basis for Dr. Brandecker’s opinion. The VA physician noted that the death certificate contained no mention of “anxiety neurosis” as a significant cause of the veteran’s death. He also noted that there were ample causes of abdominal aneurysm in the veteran, and substantiated this opinion with findings reflected in the January 1995 operation report . The VA physician characterized Dr. Brandecker’s opinion as “nonmedical” and concluded that the veteran’s death was not service-connected. Dr. Brandecker sent another letter to the RO in September 1996, in which he reiterated that he had “no data” to support a “hypothesis” that the veteran’s aneurysm would have been developed because of anxiety and neurosis. Dr. Brandecker stated, however, that in the same fashion that anxiety can exacerbate heart disease, it may perhaps exacerbate this condition. He also said that having a neuropsychiatric condition may impair one’s judgment in seeking medical attention. He said “I do not know if this was the case” but it is potentially possible. During a March 1996 RO hearing, the appellant testified as to her belief that the veteran had an aneurysm because of his service-connected nervous condition. When asked if she knew what causes an aneurysm, she said that she did not know. When asked whether any physician had ever told her that the veteran’s medications had caused the aneurysm, she said no. A March 1997 letter from the VA physician who referred the veteran to LVH in January 1995, reflects her statement that she was the veteran’s “primary care physician” at the VA Allentown Clinic before his death. The physician said that the appellant had asked her to address whether the veteran’s 50 percent service-connected condition for neurosis was related to the ruptured abdominal aortic aneurysm. (Such contact between the physician and the appellant is also reflected in a February 1995 VA Allentown Clinic record, in which the primary care physician noted that the aneurysms were not directly related to the veteran’s neurosis.) The physician’s letter stated that the veteran was treated for his anxiety continuously since his tour of duty in the service until his death, and that he had had a history of atherosclerosis since the 1970’s. The physician stated that “we know that anxiety and stress can contribute to the progression of atherosclerosis,” and that therefore, the physician was certain that “to some degree,” the veteran’s service-connected condition contributed to the development of his aneurysm. In an April 1997 letter from the RO to the VA “primary care physician,” the RO asked the physician to provide the medical treatises or other bases she used to determine that the service-connected anxiety disorder contributed to the progression of atherosclerosis. A December 1997 report of conference between the RO and the representative reflects that the physician did not respond to the RO’s letter. II. Analysis The appellant’s claim is well grounded because the file contains medical evidence which suggests that the aneurysm which caused the veteran’s death is plausibly linked to his service-connected anxiety disorder. The RO has satisfied VA’s duty to assist the appellant in the development of her claim by collecting pertinent documents, and providing her with a medical opinion regarding the etiology of the veteran’s aneurysm. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.159 (1997). The RO also provided her with a hearing and the opportunity to submit evidence. Thus, the claim is ripe for adjudication on the merits. To establish service connection for the cause of the veteran’s death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause the veteran’s death. 38 U.S.C.A. § 1310 (West 1991 & Supp. 1998); 38 C.F.R. § 3.312 (1997). For a service-connected disability to be the cause of death, the disability must singly or with some other condition be the immediate or underlying cause, or must be etiologically related. 38 C.F.R. § 3.312 (1997). For a service-connected disability to constitute a “contributory” cause, it must be shown that the disability contributed substantially or materially to death; that it combined to cause death; or that it aided or lent assistance to the production of death. Id. It is not sufficient to show that the service-connected disability “casually” shared in producing death. Id. The cause of the veteran’s death, in January 1995, was a ruptured abdominal aortic aneurysm. The other significant condition listed on the certificate of death was coronary artery disease. However, as the evidence described above indicates, his aneurysm was not manifested in service or for many years thereafter. Moreover, there is no evidence, nor is it contended, that the aneurysm or coronary artery disease was incurred or aggravated in service, or may be presumed to have been. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312(b) (1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (Table). Rather, the appellant contends that the service-connected anxiety disorder contributed to the veteran’s death. The medical evidence in favor of the appellant’s contention includes the statements of Dr. Brandecker dated in August 1995, and August and September 1996. However, notwithstanding that he reviewed the veteran’s “papers” from 1955 to the 1970’s, Dr. Brandecker admitted that he had “no data” upon which he based his opinion, and cited no treatises in support thereof. His statement only pertained to the possible formation of “an” aneurysm in the abstract, not the veteran’s aneurysm. Thus, Dr. Brandecker’s opinion has no basis in the specific facts of this case or in medical authority. Moreover, his statements that the anxiety disorder could “in some way” contribute to the development of an aneurysm is too vague and lacking in explanatory content to suggest that the anxiety disorder “materially and substantially” contributed to such development, or combined to cause death, or hastened death. See 38 C.F.R. § 3.312 (1998). Furthermore, his own letter of September 1996 characterized his statement as a “hypothesis.” Therefore, although his opinion is credible, it is per se only slightly probative. Furthermore, as noted by the September 1996 VA opinion, the certificate of death does not list the service-connected anxiety disorder as a contributing cause of death. Instead, the certifier – Dr. Brandecker, himself – left blank several spaces in which the anxiety disorder could have been inserted as a contributing cause of the veteran’s death. Yet, the January 1995 LVH summary reflects that Dr. Brandecker was aware of the veteran’s anxiety disorder and other medical problems. The Board infers from the foregoing that, even if anxiety and neurosis could “in some way” contribute to the development of an aneurysm, as Dr. Brandecker’s August and September 1995 letters indicated, Dr. Brandecker did not accord enough significance to the anxiety disorder to report it as a condition contributing to death. Therefore, his omission of such a statement on the death certificate tends to show that Dr. Brandecker actually believed that the anxiety disorder did not “materially and substantially” contribute to the development of the aneurysm, even if it “casually” shared in causing death. See 38 C.F.R. § 3.312 (c) (1998). As to Dr. Brandecker’s August 1995 opinion that the veteran might not have sought proper treatment as a result of his anxiety disorder, Dr. Brandecker admitted in September 1996 that he “did not know if this was the case” but that it was “potentially” possible. When coupled with the statement in Dr. Brandecker’s August 1995 letter that he had “no” data for his conclusions; and the fact that Dr. Brandecker had not previously treated the veteran, as reflected in the appellant’s March 1996 RO hearing testimony and the January 1995 VA treatment records, the Board concludes that Dr. Brandecker had no opportunity to observe whether the veteran could have sought proper treatment. Thus, his opinion is inconsequential in this respect. The medical evidence in favor of the appellant also includes the March 1997 etiological opinion of the veteran’s VA “primary care” physician. However, neither the primary care physician’s opinion nor the records of her prior treatment of the veteran, dated in September 1993, September and December 1994, and January 1995, reflect that she reviewed the claims file. Moreover, in stating that “we know that anxiety and stress can contribute to the progression of atherosclerosis,” she did not identify the “we” in her statement, or cite medical authority to support her opinion. Although the RO wrote to her in April 1997 to request the medical and factual bases of her opinion, she did not respond. Thus, the factual and medical predicates of her opinion are unknown. Furthermore, even if the factual and medical soundness of the VA primary care physician opinion is assumed, she stated only that she was certain that the veteran’s service-connected condition contributed to the development of his aneurysm “to some degree,” and did not specify this degree. Thus, although credible, her opinion per se is not helpful to addressing the question of whether the anxiety disorder “substantially and materially” contributed to the veteran’s aneurysm, or combined to cause death, or hastened death. See 38 C.F.R. § 3.312(c) (1998). Also, when compared to her February 1995 VA treatment notes, which reflect her opinion that the veteran’s aneurysm was not “directly” related to his service-connected neurosis, the Board finds that her March 1997 opinion has minimal probative value. In short, for the reasons noted, the Board concludes that this opinion is no more helpful than a conclusion that anxiety “casually shared” in the production of death. Id. On the other hand, the September 1996 VA examiner’s opinion reflects a review of the veteran’s claim folder (including the opinion of Dr. Brandecker), refers to medical treatises, notes the absence of anxiety disorder on the death certificate, and notes that there were multiple possible causes of the veteran’s aneurysm, as reflected in the January 1995 LVH surgical report. The VA examiner credibly concluded that there was no medical basis for Dr. Brandecker’s opinion, and that the veteran’s death was not service-connected. Due to the comprehensive nature of the September 1996 VA examiner’s report, especially the review of the entire record, the Board finds the examiner’s opinion to be more probative on the question. In comparing the evidence for and against the appellant, the Board finds that the September 1996 VA examiner relied upon a greater quantum of medical evidence as a factual predicate to his opinion than did Dr. Brandecker and the veteran’s primary care VA physician. Moreover, the examiner explored possible alternative causes of the veteran’s death, in contrast to Dr. Brandecker and the veteran’s primary care physician. Hence, the Board finds the September 1996 VA examiner’s opinion more comprehensive in its explanation of the veteran’s condition, and more closely reasoned, than the opinions of Dr. Brandecker and the primary care VA physician. There is no other medical evidence in favor of the appellant’s etiological contention. Thus, the probative value of the September 1996 VA opinion is of such persuasive value that Board finds that the weight of the medical evidence is against the appellant’s claim. See Wray v. Brown, 7 Vet. App. 488 (1995). In reaching this conclusion, the Board has considered that the VA primary care physician’s opinion might be entitled to additional weight because she was the veteran’s “primary care” physician, if her status is equated with being the veteran’s “treating physician.” See Guerrieri v. Brown, 4 Vet. App. 467 (1993), citing Masors v. Derwinski, 2 Vet. App. 181 (1992). However, there is no allegation that she was his “treating physician,” or that treatment of the veteran provided a substantial basis for her opinion. On the contrary, a review of the VA Allentown Clinic records reflects that the primary care physician only saw the veteran on five occasions – twice in September 1993, once in September 1994, once in December 1995, and once in January 1995, before he was referred to LVH – and that the veteran was treated more frequently by another VA physician. Even if she had examined him on other occasions, there is no evidence to show that her examinations of the veteran provided a factual or medical predicate that would render her etiological opinion more probative or otherwise entitled to any greater weight than previously discussed. The Board has also considered that the March 1980 VA examination report might be considered as favorable evidence to the veteran. However, the March 1980 neuropsychological examiner only questioned whether the veteran’s “chest pains” could have some emotional basis, and did not specifically address aneurysms, coronary artery disease, ASHD, or other vascular disease. Thus, the March 1980 report is of no probative value as to the cause of the veteran’s death. The appellant’s representative contends in his appellate brief that the appellant is entitled to the benefit-of-the- doubt with respect to her claim. However, the benefit-of- the-doubt doctrine only applies if the evidence for and against a claim is in relative equipoise. As the weight of the evidence is against her claim, the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the appellant contends that service connection for the cause of the veteran’s death is warranted, as a lay person, she is not competent to give a medical opinion on the diagnosis or etiology of a condition. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). ORDER Service connection for the cause of the veteran’s death is denied. MARK F. HALSEY Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). 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