Citation Nr: 1754150	
Decision Date: 11/28/17    Archive Date: 12/07/17

DOCKET NO.  12-14 464A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Des Moines


THE ISSUE

Entitlement to service connection for the cause of the Veteran's death.


REPRESENTATION

Appellant represented by:	Jodee R. Dietzenbach, Attorney at Law


WITNESS AT HEARING ON APPEAL

The appellant



ATTORNEY FOR THE BOARD

J. George, Associate Counsel


INTRODUCTION

The Veteran served on active duty from February 1966 to June 1970.  He died in May 2010.  The appellant is the Veteran's surviving spouse.   

This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

A hearing on this matter was held before the undersigned Veterans Law Judge on October 2013.

In July 2014, the Board denied entitlement to Dependency and Indemnity Compensation (DIC) benefits under 38 U.S.C. § 1318.  The Board also remanded the cause of death issue for additional development.


FINDING OF FACT

The Veteran's posttraumatic stress disorder (PTSD) aided or lent assistance in causing death.



CONCLUSION OF LAW

The criteria for service connection for cause of death have been met.  38 U.S.C. § 1310 (2012); 38 C.F.R. § 3.312 (2017).


REASONS AND BASES FOR FINDING AND CONCLUSION

The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Legal Criteria

The death of a veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death.  38 C.F.R. § 3.312(a).  The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto.  38 C.F.R. § 3.312(b).  A contributory cause of death is inherently one not related to the principal cause.  38 C.F.R. § 3.312(c)(1).  In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death.  Id.  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.  Id.; see also 38 U.S.C.A. § 1310.


Analysis

The Veteran was service connected for PTSD during his lifetime.  His death certificate lists cerebrovascular accident (CVA) as the cause of death.  The appellant contends the Veteran's PTSD caused his hypertension, which led to his CVA and death or made his CVA worse.  In September 2017, the appellant submitted a letter describing his self-isolating behavior, a symptom which is also noted in VA treatment records.

In December 2010, a VA opinion was obtained in which the examiner stated that it was less likely than not that PTSD substantially contributed or hastened the Veteran's death because the medical literature did not support PTSD as a risk factor for a CVA.

In June 2011, a VA opinion was obtained, in which the examiner opined that the Veteran's cerebrovascular accident was not the result of PTSD because there is no evidence that CVAs are cause by PTSD.  In reaching this opinion, the examiner reviewed several articles submitted by the Veteran.  With regard to these articles, the examiner commented that they do not show a medical causation between PTSD and CVA.
	
Another opinion in May 2012 noted that the Veteran's medical history was at times remarkable for uncontrolled hypertension and an aortic valve replacement, but no indication of coronary artery disease (CAD).  The examiner opined that it was less likely than not that CAD aggravated, contributed to, or caused the Veteran's death.  Importantly, the examiner noted that the Veteran was quite hypertensive on presentation to the emergency room during his CVA.

Prior to the Board hearing in this case, VA had not developed for a potential connection between PTSD and uncontrolled hypertension.  Given the evidence of record, and the appellant's contention that  there is a connection between hypertension and PTSD, the Board remanded in July 2014 for an opinion as to whether the Veteran's PTSD caused or aggravated uncontrolled hypertension which lead to the Veteran's CVA and death.  

In February 2015, an opinion was obtained in which the examiner stated that there was no medical connection between PTSD and hypertension.  The examiner also stated that the Veteran's alcohol abuse was not likely to have been contributory, because it had been in remission for many years prior to his death.  A second opinion was obtained in April 2015, in which the examiner stated that the Veteran's hypertension did not cause and was not related to his death because it had been well-controlled in the months leading up to his death.

These opinions were made without having had the benefit of the appellant's recent statement describing the Veteran's behavior in his last months, including his refusal to allow the appellant to track his blood pressure and refusal to see a doctor at his local VA Medical Center (VAMC).  Further, the February 2015 opinion ignores the May 2012 examiner's statement that the Veteran presented with uncontrolled hypertension during his CVA.

As a result, the Board requested a Veterans Health Administration (VHA) opinion from an expert under 38 C.F.R. § 20.901(a).  In May 2017, an internist from a VAMC provided an opinion that it was at least as likely as not that the Veteran's hypertension was aggravated by service-connected PTSD.  She noted that PTSD onset when the Veteran was 40.  She also discussed the myriad of studies submitted by the appellant that supported the proposition that PTSD and heart-related problems were correlated.  However, as they did not specifically address the connection between PTSD and hypertension, the expert conducted her own review of the literature that suggest PTSD has a direct relationship with the risk of developing hypertension.

She noted his daily "intrusive thoughts/memories/flashbacks" and nightmares related to the trauma every other night.  She also noted that the Veteran heard voices of sounds associated with Vietnam and was estranged from people and avoided most relationships.  She noted that blood pressure was fairly well controlled with medication for most of the last years of his life.  However, she suggested that it was possible PTSD symptoms were aggravating his blood pressure during his final hospitalization in conjunction with his CVA.  Thus, she concluded that the Veteran's hypertension was at least as likely as not aggravated by his PTSD at times in his life, including during his CVA that resulted in death.

The May 2017 VHA expert's opinion is thorough and well-reasoned.  It persuasive as it considered all of the evidence of record, including an extensive examination of the medical literature.  Thus, the Board weighs this opinion more heavily than the earlier opinions.  The Board therefore concludes, when resolving reasonable doubt in the appellant's favor, that PTSD via hypertension lent aid and assistance to the production of the Veteran's death.  See 38 U.S.C. § 5017(b); 38 C.F.R. § 3.102.  As a result, the criteria for service connection for cause of death have been met, and the claim is granted.  See 38 C.F.R. § 3.312(c)(1).  


ORDER

Service connection for the cause of the Veteran's death is granted.




____________________________________________
RYAN T. KESSEL
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs

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