The most appropriate management for this patient with metastatic non–small cell lung cancer (NSCLC) and a poor performance status is a comprehensive palliative care assessment. While systemic chemotherapy treatment with a platinum-based doublet regimen has been shown to improve both overall survival and quality of life, this has only been shown for patients with good performance status (Eastern Cooperative Oncology Group/World Health Organization performance status of 2 or better). Patients with a performance status of 2 can carry out all self-care activities and they are also active more than 50% of waking hours. This patient clearly does not meet that definition, as he is spending significant time in bed and requires help with self-care activities. For a patient such as this, chemotherapy treatment has no benefit and instead is associated with potential harm and significant negative impact on quality of life. In contrast, palliative care instituted early in the disease course for patients with metastatic NSCLC has shown to improve symptom control and improve survival.

Pleurodesis, or obliteration of the pleural space, may be helpful in managing recurrent malignant pleural effusion. However, this patient has undergone thoracentesis without evidence of recurrent effusion. Therefore, pleurodesis would not be indicated in this patient.

Radiation treatment to sites of osseous metastases is indicated only for symptom control or for stabilization of a suspected impending fracture. Neither of these is indicated to be an issue for this patient.