Recommending comprehensive palliative care assessment for possible hospice care is indicated. Stage IV (metastatic) non–small cell lung cancer (NSCLC) is incurable. Because metastatic NSCLC is a systemic process, systemic chemotherapy is typically used as the primary treatment modality. Chemotherapy for stage IV NSCLC has been shown to prolong survival and improve quality of life. However, patients with poor performance status and advanced disease have a limited prognosis (less than 4 months) despite therapy. Goals of therapy for these patients are symptom palliation and possible prolongation of survival. This patient has progressive metastatic lung cancer based on imaging studies that were obtained after she completed four cycles of chemotherapy. She also has a clear decline in functional status. Based on these findings, hospice care would be most appropriate.

The response rate to second-line chemotherapy is very low in patients with NSCLC. In addition, all available evidence indicates that patients with an Eastern Cooperative Oncology Group/World Health Organization performance status of 2 or worse do not derive benefit from chemotherapy.

Providing artificial nutrition for patients with advanced cancer has not been shown to improve outcomes and is not usually recommended.

The pleural effusion identified on the most recent imaging studies is small and is not causing respiratory compromise. Thoracostomy tube drainage is therefore not indicated.

Radiation therapy should be considered to relieve pain, particularly bony pain, visceral pain (when secondary to capsular distension), or pain due to nerve/nerve root compression. Although this patient has pain due to a metastatic lesion involving the L3 vertebral body, the pain is mild, managed with a NSAID, and there is no evidence of cord compression; consequently, radiation treatment is not needed for palliation.