Scenario – David, an 79-year-old elderly war hero with no living relatives, drove himself at night to a local hospital when he experienced shortness of breath and a headache. When he entered the emergency room (ER), he was placed in a wheelchair and briefly seen by an ER doctor. He was told that he could not be admitted since he was a veteran and had to go to a VA hospital, which was 90 miles away, for treatment. David was wheeled into the hallway to wait for transportation to a VA hospital. The night shift was busy. After sitting in the hall for 5 hours, David complained that he needed to lie down. The ER staff, who had been trying to move him to a VA hospital with no luck, finally transferred him by ambulance to a local nursing home in the wheelchair. David had a massive stroke shortly after being admitted to the nursing home and died six weeks later.
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