The most appropriate treatment is to recommend hospice care. This patient presents with worsening of his idiopathic pulmonary fibrosis (IPF). The median survival in patients with IPF is 3 to 5 years. IPF has no apparent reversible cause, and patients with IPF have an extremely poor long-term prognosis. This patient has demonstrated significant declines prior to admission with a high supplemental oxygen requirement, and he has now progressed to frank respiratory failure with hypercapnia and hypoxemia refractory to high-flow oxygen. The most common cause of death in IPF is respiratory failure.

Although high-dose glucocorticoids are often used for acute exacerbation, their efficacy remains unknown. This patient has already been treated with glucocorticoids without apparent improvement; this indicates that administration of additional glucocorticoids is not likely to be of benefit.

For individuals who develop severe respiratory distress for which there is no underlying reversible cause, intubation and supportive mechanical ventilation is of little long-term benefit. Therefore, the American Thoracic Society recommends palliation of symptoms and consideration of hospice rather than mechanical ventilation for respiratory failure due to progressive IPF.

The only intervention shown to improve survival in selected patients with IPF is lung transplantation. Given the average age of onset of disease and the increased comorbidities associated with increasing age, this intervention is only available to a small portion of patients with IPF. This patient's advanced age, comorbidities, and advanced state of his lung disease (he is likely to die prior to transplantation) make him a poor candidate for lung transplantation.