BVA9507122 DOCKET NO. 90-49 526 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Lawson, Associate Counsel INTRODUCTION The veteran was born in November 1923, served on active duty from January 1943 to August 1946 and died in November 1989. The appellant, his widow, appeals from a February 1990 decision by the Regional Office (RO) which denied her claim for service- connection of the cause of his death. The Board of Veterans' Appeals (Board) remanded the case to the RO in May 1991 for additional medical records. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that amitriptyline (Elavil by trade name) caused the veteran's fatal arrhythmia, and argues that medical statements from Elizabeth O. Palmer, M.D., a VA physician who treated the veteran, support her claim. The fact that amitriptyline was discontinued during the terminal hospitalization supports it as the cause. Its side effects can include arrhythmia, even in small doses. Notation is made about adverse cardiac reactions which can occur to amitriptyline. Consideration of the benefit of the doubt doctrine is requested. It is argued that the appellant has not been given an opportunity to submit additional evidence in response to an independent medical examination. Other contentions not listed above are described and answered in the reasons and bases section, below. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's three volume claims folder and VA treatment records folders. 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 claim for service connection for the cause of the veteran's death should be denied. FINDINGS OF FACT 1. The veteran died in 1989 from atherosclerotic coronary artery (cardiovascular) disease, with Merkel's cell carcinoma of the left neck being listed as a significant contributory cause. 3. Atherosclerotic cardiovascular disease and Merkel's cell carcinoma were not present in active World War II service or until many years after service discharge, and are not shown to have been related to service or any incident of service origin. 4. The veteran's service-connected disabilities, including a left forearm below the elbow amputation with related shoulder pain, skin irritation, and ulnar nerve neuroma (for which he was prescribed low doses of amitriptyline from September 18, 1989 until November 16, 1989), and Horner's syndrome, did not cause his death or hasten or contribute substantially or materially to cause his death. CONCLUSIONS OF LAW 1. Atherosclerotic cardiovascular disease and Merkel's cell carcinoma were not the result of disease or injury which was incurred or aggravated in service, may not be presumed to have been incurred in service, and were not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101(3), 1110, 1112(a)(1), 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310(a) (1993). 2. A service-connected disability did not cause or contribute substantially or materially to cause the veteran's death. 38 U.S.C.A. §§1310(a), 5107 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before we discuss the merits of a claim, we will first determine whether it is well grounded; that is, whether it is plausible. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1991). We conclude that the appellant's claim is well grounded. Therefore, we must determine whether the VA has fulfilled its duty to assist him pursuant to 38 U.S.C.A. § 5107. We conclude that it has. An opinion has been obtained from a medical adviser to the Board to resolve questions raised by the evidence and arguments. The question to be addressed which must be resolved in the appellant's favor in order for her to prevail on the merits is: Did the veteran's atherosclerotic cardiovascular disease or Merkel's cell carcinoma have its onset in active service, become manifested to a compensable degree within a year of service discharge, or occur as a proximate or direct result of a service- connected disability? Alternatively, did a service-connected disability, including the left forearm amputation with ulnar neuroma causing phantom pain, for which 25 milligrams of amitriptyline were prescribed from September 18, 1989 to November 16, 1989, a few hours before the veteran's death, cause or contribute substantially or materially to cause or hasten his death? The veteran's death certificate indicates that atherosclerotic coronary artery disease was the immediate cause of the 65 year old veteran's death, as does other evidence, and the death certificate lists Merkel's cell carcinoma as a significant condition contributing to death but unrelated to atherosclerotic cardiovascular disease. It is not argued or shown that atherosclerotic cardiovascular disease or Merkel's cell carcinoma was present in service or to a degree of 10 percent within one year of service discharge, or that either was proximately due to or the result of a service-connected disability. Accordingly, the provisions of 38 U.S.C.A. §§1101(3), 1110, 1112(a) and 38 C.F.R. §§ 3.303, 3.304, 3.307, and 3.309 (permit service connection for disabilities resulting from disease or injury incurred or aggravated in wartime service or atherosclerotic cardiovascular disease or carcinoma manifested to a degree of 10 percent within one year of service discharge) do not assist the appellant. It is noted, however, that service medical records were negative for cardiovascular disease or skin cancer and that blood pressures, chest x-rays and examinations of the skin in service were negative for pertinent defects. The question over which there is controversy is whether the medication amitriptyline that the veteran received for phantom pain on account of his service-connected left forearm amputation caused or contributed substantially or materially to cause or hasten the veteran's death. The regulation pertinent to determining whether the cause of death is service-connected given the controversy is 38 C.F.R. § 3.312. 38 U.S.C.A. § 1310(a). 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). It is considered the principal cause of death when it, 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). For it to be a contributory cause of death, it must be shown that it contributed substantially or materially to cause death. 38 C.F.R. § 3.312(c). VA hospital reports dated in October 1979 indicate that hypertension was diagnosed and that he had been on medication therefor for three years He was using a nitroglycerin patch in December 1985. In September 1986, there was reported a history of severe restrictive lung disease secondary to silicosis requiring home oxygen, stable angina and hypertension controlled by medication. Coronary artery disease and aortic stenosis were reported in December 1987. In September 1988, he had cardiac arrhythmia with a harsh systolic murmur. VA hospital reports in June and July 1989 indicate multiple tumors of the skin, and he was diagnosed at that time as having Merkel's cell small cell carcinoma of the skin. His medications up to this point did not include amitriptyline. During this hospitalization, he underwent chemotherapy for the Merkel's cell carcinoma. During VA hospitalization in July 1989, it was noted that he had presented to the hematology clinic for an appointment the day beforehand, at which time there was marked painful swelling in his right forearm. The swelling did not subside with antibiotics, and he was admitted. During the hospitalization, multiple tumors of the skin were diagnosed, as were hypertension and congestive heart failure. A September 1989 VA hospital discharge summary indicates that infectious or chemotherapy-induced mucositis and Merkel cell cancer of the lip and neck were diagnosed. Hypertension and coronary artery disease with occasional angina were also diagnosed. On September 18, 1989, following the VA hospital discharge, he was seen in the VA neurology clinic for chronic headaches on the left side. The assessment was post sympathectomy pain (the veteran had had a recent cervical sympathectomy), and Elavil (amitriptyline), 25 milligrams per day before bedtime was prescribed, as was follow-up treatment in one month. A VA hematology clinic record dated October 16, 1989 states that the veteran reported that since his last chemotherapy, he had been coughing up blood for a duration of approximately two weeks, had left sided painful lymph nodes, and was losing weight. He weighed 153 pounds(his height was 67 inches). A chest X-ray of October 9 had shown distended bowel loops. The hematology clinic note does not indicate that there had been an adverse reaction to amitriptyline. A several page VA medical report dated October 22, 1989 states that on physical examination, the heart exhibited a normal rate and rhythm with a grade II/VI systolic ejection murmur at the left sternal border. He had not, unfortunately, responded to either radiation therapy or chemotherapy. In response to the question of whether there had been an adverse reaction or drug allergy, the physician checked "No". A November 14, 1989 VA tumor board conference report indicates that the veteran had had salvage chemotherapy for one cycle in early November 1989 for Merkel's cell carcinoma. It was performed on the presumption that if it were ineffective, he would probably die of widespread Merkel's cell carcinoma disease, but that at least the chemotherapy would provide some relief from his neck masses. Palliative radiation and chemotherapy to local disease were recommended. The veteran was hospitalized at a VA hospital on November 16, 1989. It was reported that he had been discharged from the VA hospital on November 8, 1989 after a course of chemotherapy and had returned on November 15, 1989 for a CT scan of the head. Since the evening of November 15, 1989, he had had nausea and vomiting on several occasions without any coffee ground emesis or bright red blood. A doctor of the Renal Service had requested the veteran's admission for hydration after an acute dye load. Clinically, his cardiovascular system at that time exhibited a regular rate and rhythm with tachycardia and a grade II/VI systolic ejection murmur at the left sternal border. A correlation of the hospital discharge summary with other records including prescription and nursing notes indicates that the veteran was admitted for suspected possible renal insufficiency after his recent platinum based chemotherapy. Biopsy had already shown metastatic Merkel cell tumor. One doctor believed he needed to be admitted for IV fluids and Mannitol due to renal insufficiency secondary to IV dye or cis- platinum. An admission note indicates that he was overly pale, tired looking, short of breath, anxious, and fearful. IV Mannitol with Lasix was prescribed. The terminal hospital report indicates that this was to increase his urine output, with an additional IV to match his urine output. He was given Compazine for nausea and vomiting. He did fairly well. Continuing medication records indicate that the first and only dose of amitriptyline during the hospitalization was 25 milligrams administered orally at 2100 hours (9 p.m.) on November 16, 1989. The hospital discharge summary and a nursing note indicate that at approximately 9:35 or 9:40 p.m., a nurse heard a loud noise and crashing sound in his room and found him on the floor. He was breathing and was unresponsive for approximately five to ten seconds, and then awoke. He had no recollection of what had happened to him. He was found by the medical staff to be acutely short of breath, cold, and clammy. He was put back to bed and a EKG showed what appeared to be atrial fibrillation flutter with right bundle branch block pattern verses sinus tachycardia at a rate of approximately 140. Stat electrolytes were obtained, and then blood gases. A differential diagnosis at that time included pulmonary embolism and gastrointestinal bleeding. The veteran was transferred to a medical intensive care unit (MICU) on or after 11:00 p.m.. Within 20 minutes of arriving at the MICU, he became hypotensive with systolic blood pressure of 80. He was bolused with normal saline and became normotensive. Subsequently, he vomited coffee ground emesis. He was subsequently started on Cimetidine and given increments of IV magnesium, sulfate, and potassium to replete his electrolyte abnormalities. One dose of Digoxin was administered about two hours into the course of potassium and magnesium increments. A VQ scan was considered but in light of coffee ground emesis, it was elected not to anticoagulate him. He appeared to stabilize while in the MICU and felt much better upon arrival there with repletion of fluids. At approximately 2:25 a.m., Dr. Heart (a code name for an acute heart problem) was called on him. He was found with his feet over the side of the bed with a large amount of coffee ground emesis present on the sheets. Cardiac monitor showed at first atrial fibrillation flutter, which then appeared to deteriorate into AV dissociation with subsequent asystole. The veteran immediately began receiving cardiopulmonary resuscitation and was intubated. He received epinephrine times three, atropine times two, bicarb, and three shocks in the event that this was fine ventricular fibrillation. American College of Life Saving protocol was carried on for approximately twenty minutes but was unsuccessful. He was pronounced dead at 2:41 a.m. A doctor who treated the veteran in the hospital during the terminal course of events gave on a November 17, 1989 death summary a description of the terminal events and listed the presumed cause of death as "Cardiopulmonary arrest (next line) Metastatic Merkel's cell tumor (next line) New GI (gastrointestinal - ed.) bleed." Recent problems were a new gastrointestinal bleed and a new right bundle branch block. An autopsy was requested to determine the cause of death, the presence of a pulmonary embolism, or a perforated ulcer. The autopsy report indicates that the veteran had been admitted for work-up of renal failure thought to be secondary to IV dye or cis-platinum therapy. On autopsy examination, he weighed 145 pounds and was inadequately hydrated. Internally, the distal aorta had moderate atherosclerosis distal to the renal ostia. The pulmonary conus was devoid of emboli. The pulmonary arteries were nonatherosclerotic. The gastrointestinal tract exhibited no areas of bleeding. The first final anatomic diagnosis was atherosclerotic cardiovascular disease with moderate to severe (50 to 75 percent) stenosis of the left anterior descending coronary artery, mild right coronary artery and left circumflex artery stenosis, a remote anterior septal myocardial infarction, and subendocardial fibrosis. The second final anatomic diagnosis was Merkel cell tumor with a head and neck primary. The final comment to the autopsy report states that atherosclerotic cardiovascular disease is the most common cause of death in the United States. Its complications include ischemia and infarction. It stated that in summary, the veteran was a 65 year old male being treated with chemotherapy for Merkel cell tumor of the neck who developed a fatal arrhythmia in the setting of chronic ischemic heart disease and a remote myocardial infarction. References were cited. In December 1989, a doctor wrote a letter to the appellant's representative stating that she was the physician in charge of the veteran during his final hospitalization and that it was her opinion "that his death was a result of a cardiac arrhythmia. It is possible that the arrhythmia was caused by the medication Amitriptyline that he was taking for his phantom limb pain." In May 1990, the appellant's representative submitted a number of materials. One was an April 1990 letter from the above doctor in which she stated that the veteran had had several medical problems including coronary artery disease, idiopathic hypertrophic subaortic stenosis, restrictive lung disease, and severe phantom pain which was a result of the traumatic amputation of his left arm. In the last six months of his life, he had been diagnosed with Merkel's cell cancer of the skin. He began chemotherapy and had an excellent response. He continued to have severe phantom pain in his left arm stump, and was placed on Elavil at the recommendation of neurology. He was subsequently admitted, it was stated, to the VA hospital on November 16, 1989, with nausea, vomiting, dehydration, and palpitation. She admitted him. Later that evening, he was found on the floor of his room quite disoriented with a rapid, thready pulse and borderline hypertension. An EKG demonstrated atrial fibrillation/flutter. He was moved to MICU and given IV fluids, potassium, and Digoxin for control of his rapid ventricular rate. He appeared to stabilize, but at 2:00 a.m., a cardiac arrest code was called on him. He was found to be in asystole and died. The autopsy report states that he died from a cardiac arrhythmia. "Of special note on the autopsy findings was that he had sustained an old myocardial infarction, and had fibrosis of his cardiac conduction system." It was the doctor`s opinion that the veteran died from a cardiac arrhythmia. She believed that Elavil had played a role in precipitating his fatal cardiac arrhythmia. She had done an extensive literature search on the adverse effects of Elavil on cardiac function. She conceded that the majority of the literature discusses adverse effects of the drug given in high doses. The studies, however, failed in her opinion to take into account the increased likelihood of adverse effects in patients with underlying cardiac disease. This could be seen, she opined, even with low doses. She summarized that she believed that Elavil contributed to the untimely death of the veteran in light of his multiple underlying cardiac problems. An April 1990 Albuquerque Tribune article to which she referred states that major side effects of Elavil include heart attack, heart block, rapid pulse, low blood pressure, seizures, disordered thinking, and headache. The article was written by a physician. In a March 1990 letter from the appellant, she indicated that the VA doctor who prescribed amitriptyline for the veteran told him to take one tablet at bedtime, explained the importance of staying with the medication, and advised the veteran to do so. A 1987/1988 Compendium of Drug Therapy publication notes that Elavil, especially in high doses, may produce arrhythmias, myocardial infarction, and stroke. Its adverse reactions could include hypotension, hypertension, tachycardia, palpitations, myocardial infarctions, arrhythmias, heart block, and stroke. 28:16 Psychotherapeutic Agents (American Society of Hospital Pharmacists, selected revisions 1984) states that amitriptyline has direct cardiotoxic properties which in conjunction with indirect cardiac effects may produce a variety of cardiovascular disturbances such as ECG changes, tachycardia, and postural hypotension. Patients with preexisting cardiovascular disease may be especially sensitive to the cardiotoxicity of the drugs. Cardiac irregularities may be especially serious in geriatric patients or in patients with cardiac or renal disease. Cardiorespiratory arrest, congestive heart failure, shock, and delayed cardiac death have occurred. Occasional manifestations of overdosage have included renal failure and vomiting. Other cardiovascular effects include T-wave flattening, conduction disturbances such as bundle branch blocks, and atrioventricular blocks, various arrhythmias including ventricular tachycardia, ventricular fibrillation, collapse, sudden death, and congestive heart failure. Amitriptyline should be used with extreme caution in patients with preexisting cardiovascular disease because it may cause adverse cardiovascular effects. In August 1994, the Board requested a medical review and opinion as to whether amitriptyline caused the veteran`s death or fatal arrhythmia or significantly contributed to it. A December 1994 letter from a cardiologist states that he is a professor of medicine at Emory University School of Medicine and the director of the division of cardiology therein. It was noted that the veteran died of a terminal cardiac arrhythmia and that he had "had electrolyte abnormalities in the form of severe hypokalemia and hypomagnesemia that were sufficient in and of themselves to cause fatal arrhythmias in the setting of documented heart disease." The independent expert`s letter stated that "(w)hile a role for the low dose of amitriptyline cannot be specifically excluded, I view it as unlikely to have been an important contributor" in the veteran's death. The opinion from the doctor was attached to the letter. The expert`s opinion indicates that he reviewed the veteran's claims folder. It notes that on admission to the VA hospital, the veteran's medications included verapamil, 80 mg every eight hours, amitriptyline for phantom pain, 25 mg every night, Compazine for nausea and vomiting, Dulcolax once a day, and Percocet as need for pain. It noted that on admission, the veteran's pulse was 122 and his respirations were 22, and his blood pressure was 122/64. He was in mild distress from nausea, and his lungs exhibited some rales. He had tachycardia with a regular a regular rhythm and a II/VI systolic ejection murmur at the left sternal border. The veteran's abdomen was unremarkable and his stool was trace guaiac positive. His sodium was 132 and his potassium was 3.4. Magnesium was 1.1. Hematocrit was 34.5, and white cell count was said to be "0.4". It was noted that the veteran was admitted to the ward with a diagnosis of renal insufficiency and was treated with intravenous Mannitol and Lasix 100 mgs. to run at 20c.c. per hour for 12 hours. He was also given half normal saline with 80 milliequivalents of potassium per liter to run a rate to equal to urine output. The doctor also noted that the veteran was heard to fall and was found to be unresponsive for a brief period of time, and that he subsequently became responsive and was found to be tachycardic. An electrocardiogram showed a heart rate of approximately 140 with a new right bundle branch block and a vertical axis. The rhythm was likely sinus tachycardia. The old anterior q-waves in V3 and V2 were still apparent. He stated that there was no acute evidence of myocardial infarction on the EKG. Of note, he reported, the veteran's electrolytes at that time included a potassium of 2.8 and a magnesium of 1.2. This occurred at about 9:35 p.m., he noted. He noted that the veteran had been given his usual dose of amitriptyline at 9:00. Thereafter, the veteran was transferred to the medical intensive care unit. His systolic blood pressure was 80 and he was given 500c.c. of normal saline. He subsequently vomited coffee ground emesis, and Cimetidine was added. A ventilation perfusion scan was considered but was not performed. There was hesitancy to anticoagulate the veteran because of the coffee ground emesis. A pulmonary embolus was being considered. The expert physician noted that at 2:25 a.m. on November 17, the veteran had a code called and was found with his feet over the side of the bed and had very large amounts of coffee ground emesis. A cardiac monitor showed atrial fibrillation, flutter, then AV dissociation then asystole. The veteran received CPR and was intubated. He received epinephrine, atropine HC0-3, but was pronounced dead at 2:41 a.m. The autopsy results showed an old anterior septal myocardial infarction of a limited extent with some patchy fibrosis, a 70 percent left anterior descending lesion without comment of acute clot, moderate non-obstructive disease in the right coronary artery and circumflex, unremarkable valves, and no evidence of acute infarction. It was noted that lungs showed evidence of chronic lung disease but no pulmonary emboli or acute infection. The gastrointestinal tract showed no evidence of source of bleeding or active blood in the gastrointestinal tract. Then, it was noted that the veteran was admitted to the hospital with evidence of dehydration that was probably from nausea and vomiting. He had mild renal insufficiency which may well have been pre-renal or could have been related to contrast. "Very importantly," he emphasized, the veteran had marked hypokalemia with the last measured potassium at 2.8. He reported that the veteran also had hypomagnesemia with magnesium of 1.1 and 1.2. He stated that "(e)lectrolyte abnormalities of this magnitude would be sufficient in and of themselves to cause, in the setting of pre-existing heart disease, fatal arrhythmias." He felt that it appeared very likely that the veteran's first syncopal episode was related to a ventricular arrhythmia even though this was not documented. The expert stated that the major issue was whether amitriptyline which the veteran was taking in small doses could have contributed to the veteran's death. The doctor did "not consider it likely that the amitriptyline was playing a major role because of the relatively low dose. It is highly unlikely that the dose given orally at 9:00 on the evening of the patient's demise was a proximate cause of his problem." It was noted that amitriptyline is not excreted predominantly by the kidneys and that it was unlikely that the veteran's acute change in renal function would have caused excessive accumulation of the drug. He noted that the veteran's emeses between 11:00 and 11:30 may have caused him to regurgitate what residual he may have had in his upper tract. The cardiology expert stated that, in summary, the veteran died of a terminal cardiac arrhythmia characterized as an asystole. He felt that it "very likely was related to severe electrolyte abnormalities." He stated that while a contribution of amitriptyline could not be specifically excluded, the veteran's severe electrolyte abnormalities "were in and of themselves sufficient to cause terminal arrhythmias." Weighing the evidence, the Board concludes that it preponderates against a finding that amitriptyline caused or contributed substantially or materially to cause or hasten the veteran's death. He had atherosclerotic cardiovascular disease long before he started receiving amitriptyline on a daily basis, and the atherosclerotic cardiovascular disease had grown more severe as time went on. He was receiving a small dose of amitriptyline prior to his terminal hospitalization, and his death from widespread Merkel's cell carcinoma had been expected before the terminal admission. The independent medical expert in cardiology who reviewed the entire claims folder and assembled records is a professor of cardiology. He considered the facts as they led up to the veteran's death very carefully and in detail. His reasoning for his opinions seem to be the most persuasive. He considered all the appellant's vital statistics, his health state prior to hospitalization, and the effect that amitriptyline could have had on the veteran. He stated that the grounds for rejecting the premise that amitriptyline had anything to do with the veteran's death were sound, in that the veteran had poorly functioning kidneys prior to hospital admission and vomited shortly after taking it, so the drug, which was already in a low dose, would not have accumulated excessively enough to have an effect on the veteran. He also found that the veteran's dehydration existed prior to hospitalization and was probably from nausea and vomiting. He also noted that the veteran had severe electrolyte imbalances prior to taking his amitriptyline the night of his death, and felt that the veteran's terminal cardiac arrhythmia was very likely related to the severe electrolyte abnormalities. After the veteran died, one VA treating doctor opined as to a relationship between amitriptyline and the death. At first, she stated only that a relationship was "possible". Later, she "believe(d)" that Elavil "played a role" and "contributed" to the death. Additionally, she did not review the veteran's complete claims file and medical records as the independent expert did. The independent expert considered the differential possible causes for the veteran's arrhythmia, such as amitriptyline, dehydration from vomiting, and hypomagnesemia and hypokalemia and had access to the contentions and other medical opinion. His opinion based on a review of the entire record is thus most probative of the cause of the veteran's death. Furthermore, the Board takes note of the tumor board report, the death summary, the death certificate, and the report of autopsy, none of which point to amitriptyline as a cause of death. The Board finds additionally persuasive the facts that the hematology clinic note after amitriptyline was prescribed listed no drug allergy or adverse reaction. Additionally, amitriptyline was prescribed only for a short period of time, and the expert reviewed the progression of the veteran's atherosclerotic cardiovascular disease as shown by VA medical records. He considered the various possible causes for the arrhythmia. Additionally, the veteran had been seen for weight loss and coughing up blood in October 1989. This was the result of chemotherapy for the Merkel's cell carcinoma, which was expected to cause his death. The veteran's weight loss continued to the time of his death. At the time of the tumor board conference on November 14, 1989, it was noted that he had been expected to die from widespread metastases as of early November 1989, if salvage chemotherapy was unsuccessful. Overall, the evidence is more persuasive that amitriptyline did not either cause or contribute substantially or materially to cause the veteran's death, than that it did. Accordingly, the benefit of the doubt doctrine at 38 U.S.C.A. § 5107(b) is not for application. Gilbert v. Derwinski, 1 Vet.App. at 55 (provides that if the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied). The representative contends that since there are two VA physicians`(a treating doctor during hospitalization and a Board medical advisor) opinions reaching opposing viewpoints, the benefit of the doubt doctrine is for application, and the appellant should thus prevail. It does not apply, however and the Board medical advisory opinion may not be considered. See Austin v. Brown, 6 Vet.App. 547(1994). The evidence against the claim is more weighty than that in favor. It is not a question of how many opinions are in favor as opposed to against the claim, but how persuasive and reasoned the evidence is overall, and here, overall, it clearly preponderates against the claim. For instance, the independent medical opinion, the tumor board report, death summary, autopsy report, and death certificate all work strongly against the claim. In response to the appellant's contentions, the Board notes that amitriptyline was not discontinued during the terminal hospitalization. It was not supposed to have been prescribed again until 9 p.m. the night of the 17th (prior to going to sleep). While the appellant feels that the veteran became zombie-like during the week and a half before he received chemotherapy, and that this was due to the effects of the tranquilizer amitriptyline in his system, there is no proof that this is true, or that it, in fact, caused the veteran's arrhythmia and death. She is not qualified, as a layperson, of providing competent evidence as to medical matters such as the etiology of the veteran's arrhythmia. Espiritu v. Derwinski, 2 Vet.App. 492, 495 (1992). Espiritu, 2 Vet.App. at 495, precludes another one of her contentions from proving that 'amitriptyline affected and weakened a vital organ (his heart), and so should be considered to have had a material influence on his death, and that amitriptyline weakened his heart in such a way that he could not withstand the effects of chemotherapy, namely dehydration and hypokalemia.' Her argument that since there is no indication in the literature of the amount of the dosage which would be harmful, so dismissing the amount he was taking as insignificant is illogical, is not persuasive. There are indications in several pieces of evidence of record that dangers are more probable particularly in higher doses. Physicians may take this type of factors such as this into account in making their professional opinions. In response to the appellant's notation in the autopsy report that the myocardial infarction to which the pathologist referred was in April 1987, the Board notes that the pathologist was aware of this, and appears to have felt that the prior myocardial infarction had had an effect or been an important variable anyway. The appellant, being a layperson, can not offer competent evidence to the contrary merely with a contention. Espiritu, 2 Vet.App. at 495. As to her contention that the cause of death on the death certificate, atherosclerotic cardiovascular disease, was a preliminary diagnosis, completed before the autopsy report, the Board notes that the findings of the autopsy were considered in determining the cause of the veteran's death, according to box 24b of the death certificate. A pathologist conducted the autopsy and signed the death certificate. The appellant's contention that the veteran had a preexisting cardiovascular disease and thus may have been especially sensitive to the cardiotoxicity of amitriptyline, and that since the primary route of elimination of the drug was urinary excretion, the veteran's dehydration and chemical imbalance would in all likelihood have contributed to the retention of the drug in his system has an Espiritu flaw in it. Additionally, the argument is of limited value, as it points out that he was severely dehydrated and chemically imbalanced from chemotherapy for a nonservice-connected disability, Merkel's cell carcinoma. The appellant was given a fair opportunity to submit additional evidence or argument in response to the independent medical examination report. The VA satisfied its duty to provide her with a copy of the report and a time limit within which to respond in its December 1994 letter to the Disabled American Veterans, which represents the appellant. Notice to the representative is deemed notice to the appellant. ORDER Service connection for the cause of the veteran's death is denied. SAMUEL W. WARNER Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), 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 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.