The hospital admitted a 96-year-old male patient due to a fall. After a medical workup, the healthcare team determined that the patient had a nonoperative hip fracture. He then experienced a medical deterioration requiring intubation and did not have decision making capacity. His power of attorney for health care (POA) agent visited daily and a conversation occurred with the medical team about the patient’s health treatment preferences. The patient’s POA agent explained to the medical team the patient’s wishes were “extensively detailed in his advanced directive” and “everything was taken care of”. How can healthcare providers collaborate with the patient’s POA agent and additional supportive family members to make sure the patient’s code status reflects the wishes she states in her advanced directive and that she has a POLST form reflecting those preferences once she is medically ready for discharge to a skilled nursing facility for rehabilitation?