Opinion
NA-xxx/17
04-27-2017
In the MATTER OF MATTHEW V., A Child under Eighteen Years of Age Alleged to be Abused by Lynette G., Respondent.
Alan Sputz, Esq., Special Assistant Corporation Counsel, Administration for Children's Services, Family Court Legal Services, 330 Jay St., 12th Floor, Brooklyn, NY 11201, By: Caroline Irvin, Esq., Andrew Friedman, Esq., Friedman Sanchez LLP, 16 Court St., Suite 2600, Brooklyn, NY 11241, Counsel for Lynette G. Maria Roumiantseva, Esq., Legal Aid Society, Juvenile Rights Practice, 111 Livingston St., 8th Floor, Brooklyn, NY 11201, Attorney for the Child
Alan Sputz, Esq., Special Assistant Corporation Counsel, Administration for Children's Services, Family Court Legal Services, 330 Jay St., 12th Floor, Brooklyn, NY 11201, By: Caroline Irvin, Esq., Andrew Friedman, Esq., Friedman Sanchez LLP, 16 Court St., Suite 2600, Brooklyn, NY 11241, Counsel for Lynette G.
Maria Roumiantseva, Esq., Legal Aid Society, Juvenile Rights Practice, 111 Livingston St., 8th Floor, Brooklyn, NY 11201, Attorney for the Child
Erik S. Pitchal, J.
By petition dated April 20, 2017, ACS alleges that the respondent, Lynette G., abused her 13–year-old son, Matthew V. The gravamen of the petition is that Matthew is diagnosed with Ewing sarcoma, the only indicated treatment for which is chemotherapy, and that Ms. G. is unreasonably refusing to consent, putting the child's life at risk.
With the filing of the petition, ACS sought a court order giving it medical decision-making authority for Matthew. ACS did not seek a remand of the child or the transfer of any other parental or custodial duties, recognizing that as he goes through chemotherapy, the child would be best off remaining in his mother's care. The matter was transferred to the undersigned for the purpose of a hearing on the issue.
Prior to commencing the hearing, the Court confirmed, on the record, that if the Court were to grant the ACS application, Ms. G. would obey the order and bring the child to chemotherapy appointments despite her objection to them, obviating the need to expand the scope of the hearing to consider a full remand. Also prior to commencing the hearing, the Court ascertained that the child also opposed chemotherapy, and thus the attorney for the child would be opposing the ACS application. Nevertheless, the attorney for the child noted the importance for the child to receive independent counseling from a licensed mental health professional familiar with pediatric cancer issues, so that, in the event the Court granted the ACS application, Matthew could be emotionally prepared to accept the result. Ms. G. indicated that she would consent to such counseling.
The Court also inquired regarding Matthew's father, and was informed that Mr. V. resides in Florida and is in touch with Matthew and Ms. G. He is also said to oppose the chemotherapy treatment plan.
The hearing commenced on April 21, 2017, and continued on April 25, with closing arguments delivered on April 27. The record at the hearing consisted of the credible testimony of ACS child protection supervisor Ms. Tonza Smart and Dr. Alice Lee (qualified by stipulation as an expert in pediatric oncology), and the testimony of Ms. G., which the Court found credible in some respects and not credible in others, as detailed below; Petitioner's Exhibits 1 (Memorial Sloan Kettering Cancer Center records) and 2 (ORT dated March 30, 3017); and Respondent's Exhibit A (MRI report dated April 17, 2017), B (hematopathology report dated March 3, 2017), C (pediatrician letter dated April 24, 2017), and D (CT scan report dated April 21, 2017). Based on the record, the Court makes the following findings of fact:
Additionally, at the attorney for the child's request, and without objection from counsel for ACS and the mother, the Court conducted a brief in camera interview with Matthew. The conversation focused solely on Matthew's feelings and opinions about his medical situation.
1. The child Matthew V. was born on xxxx, 2003, and is 13–years-old.
2. Matthew and his mother first noticed a pea-sized mass on the left side of his neck in approximately 2014. They thought it was a benign cyst. Over the years, it grew in size, and by December 2016, Matthew was complaining of discomfort
when he turned his head to the left.
3. Ms. V. brought Matthew to the emergency department at Morgan Stanley Children's Hospital of New York/New York–Presbyterian ("CHONY"). CHONY staff told the family that, based on imaging, the mass was not a cyst, and surgery was recommended.
4. Dr. Duron performed surgery and excised the mass on January 7, 2017. Pathology examination showed the margins to be clear.
5. However, Dr. Alice Lee, the pediatric oncologist at CHONY also informed Ms. V. that Matthew has Ewing sarcoma. This was based on the genetic testing done on the mass that Dr. Duron
removed, which revealed an EWS–ERG fusion. Moreover, a chest CT scan revealed three tiny nodules on his lungs, which were too small to biopsy.
6. Ewing sarcoma is a type of tumor found in soft tissue or bones, which most typically strikes adolescents and young adults. Systemic chemotherapy is the standard treatment for this kind of cancer. When Ewing sarcoma metastasizes, it most commonly spreads to the lungs, other bones, and bone marrow, but it can travel anywhere in the body. CHONY conducted a PET scan to assess the presence of disease elsewhere in his body, and the results were negative. CHONY also conducted a bone marrow biopsy to determine if he had cancer in his bones, and the result was negative.
7. Nevertheless, because of the definitive diagnosis of Ewing sarcoma, Dr. Lee recommended initiation of systemic chemotherapy. She believed the nodules in Matthew's lungs were evidence that the cancer had spread there. Ms. G. was reluctant and wanted a second opinion.
8. Ms. G. arranged for a second opinion at Memorial–Sloane Kettering Cancer Center ("MSKCC"). MSKCC was provided various tissue slides from CHONY to conduct their own examination and testing. As early as March 3, 2017, a hematopathologist at MSKCC, Dr. Wenbin Xiao, examined slides of a bone biopsy conducted by CHONY on January 26, 2017 and found no evidence of metastatic disease.
9. Another MSKCC pathologist, Dr. Cristina Antonescu, reviewed the biopsy slides of the mass that had been removed by CHONY. From her initial histology review, she did not think the cells were completely consistent with Ewing sarcoma. Her first method of genetic testing led her to think that Matthew may have a myoepithelial carcinoma instead, so she performed a different type of genetic testing to be certain.
10. The indicated treatment for myoepithelial carcinoma is quite different than the systemic chemotherapy indicated for Ewing sarcoma. For a myoepithelial cancer, MSKCC would recommend more surgery at the cancer site, to remove a greater area of tissue, as well as possible post-surgical radiation therapy.
11. When Ms. G. brought Matthew for an in-person consultation at MSKCC on March 22, 2017, the pediatric oncologist, Dr. Paul Meyers, informed them of Dr. Antonescu's findings, her plan to perform additional genetic testing on the tumor sample,
and the different treatment recommendations depending on the results of that testing. The family also met on March 24, 2017, with Dr. Todd Heaton, the pediatric surgeon, who explained the excision he would perform in the event Dr. Antonescu diagnosed Matthew with myoepithelial carcinoma rather than Ewing sarcoma.
12. MSKCC performed an MRI on Matthew's neck on March 22, 2017, and found no recurrence of the tumor.
13. On or about March 25, 2017, Dr. Antonescu finished her testing and finalized her report and ultimate diagnosis: Matthew does have Ewing sarcoma. She confirmed the presence of the EWSR1–ERG fusion, concluding that he has a Ewing sarcoma"with an unusual phenotype and immunoprofile." Ultimately, the phenotype does not matter to the diagnosis; the genetic analysis governs.
14. Ewing sarcoma comes in two stages, local—meaning that the disease is limited to one location—or metastatic—meaning that the disease is in more than one place. The survival rate at five years for patients who have metastatic Ewing sarcoma and who follow the standard treatment of systemic chemotherapy plus radiation at the tumor site(s) ranges between 15 and 30 percent. If left untreated, the survival rate is under 10 percent.
15. MSKCC repeated a chest CT scan to compare to the baseline taken in early January at CHONY. The MSKCC scan, performed March 27, 2017, showed several nodules on Matthew's chest, determined to be "possible" (defined as approximately 50%) metastatic disease. Though Dr. Lee did not review the MSKCC report, according to her credible testimony, Dr. Meyers informed her via e-mail that one of the nodules had grown since the CT scan done at CHONY in January. While an MRI of Matthew's lung taken April 17, 2017, showed only one nodule, CT scans are the preferred method for imaging the lungs because of the motion artifact of breathing present in MRIs. Thus, Dr. Lee remains convinced that Matthew does have metastatic Ewing sarcoma.
16. Even if the chest scan had been clear—meaning that even if Matthew's disease were determined to be local as opposed to metastatic—MSKCC would still recommend that Matthew immediately commence systemic chemotherapy. Dr. Lee also testified that regardless of whether the sarcoma were local or metastatic, she recommends immediate standard chemotherapy treatment. The risk of recurrence without such treatment
is 95%. The survival rate is much higher for patients who commence chemotherapy before tumors recur. In the opinion of Dr. Meyers, "Matthew's life is at risk" absent immediate systemic chemotherapy. Dr. Lee concurred: the reason to start chemotherapy now is because he has Ewing sarcoma, regardless of its stage.
17. Ms. G. does not trust Dr. Meyers's opinions, concluding that he was unduly influenced by another pediatric oncologist at MSKCC, Dr. Chou, whom she adamantly opposed involving in Matthew's treatment. The Court finds Ms. G.'s denunciations of Dr. Chou to be not credible and bordering on paranoid. She believes, irrationally, that Dr. Lee, who told her she knows Dr. Chou well, colored Dr. Chou's thinking about Matthew's case, and that Dr. Chou in turn biased Dr. Meyers. That Dr. Chou's name appears on some of Matthew's MSKCC records does not mean that he was unduly influenced by Dr. Lee or involved at all in formulating the MSKCC diagnosis and treatment recommendation. Ms. G.'s claim that she did not get an independent second opinion is not true.
18. For primary care since 2014, Matthew has attended a pediatric clinic where his provider is a physician's assistant named Mr. King. Mr. King was informed of the recommendations by CHONY and MSKCC and concurs with the treatment recommendations.
19. No medical professional has recommended that it is a reasonable medical decision for Matthew to forego chemotherapy.
The Court does not credit Ms. G.'s testimony that she found information on "reputable websites" that some doctors treat local Ewing sarcoma with radiation alone, without chemotherapy. Nor does the Court credit her testimony that she has been in contact with the clinic of Dr. Stanislaw Burzynski in Houston, as there is no credible evidence in this record that his alternate treatment methods could cure Matthew's cancer, and he was recently put on probation and fined by the Texas Medical Board.
20. Even if the lung nodules are not evidence of metastatic Ewing sarcoma, and even if he seems perfectly healthy, it does not mean that Matthew is disease-free. A 95 percent chance of recurrence means that he most likely still has disease inside his body that cannot currently be detected. Surgery alone does not treat any residual tumor that cannot be seen; cancer cells are likely circulating and growing in his body.
21. Indeed, it has not been proven scientifically that surgery alone is sufficient therapy for Ewing sarcoma. Matthew is doing
well physically because the overall disease burden he is experiencing is low. But because it is impossible to predict where in his body the disease will recur, if it does, it is impossible to state how easy or hard it will be to treat it at that time. More areas of the body that are attacked by cancer cells means that there would be more areas that need to be treated with radiation. A higher burden of tumor may mean that treatment is less effective; there would be more cells to kill.
22. There is no other treatment that is medically proven to cure Ewing sarcoma other than systemic chemotherapy. Homeopathic, nutritional, and lifestyle-change interventions may complement chemotherapy and possibly contribute to the patient better tolerating the medicines, but alone they have not been demonstrated to cure Ewing sarcoma.
23. Nevertheless, Ms. G. opposes chemotherapy at this time. She believes that the nodules on his lungs are not evidence of metastatic disease, and that, since there is a 5 percent chance of non-recurrence after surgical excision of a local Ewing sarcoma mass, she prefers to wait to see if Matthew falls into that small category of patients. She does not fully believe that he may have microscopic cancer cells in his body. She is influenced by the fact that Matthew is not sick, and she has changed his diet. She irrationally believes that the natural treatments she is providing him—which really amount to no more than a healthy diet—will result in "90% sure" of a cure. Elsewhere in her testimony, she claimed that changes to the nodules detected in scans in April (Resp. Ex.'s A and D) prove that his cancer is "improving," tacitly concurring with Dr. Lee's assessment that the nodules represent metastatic disease.
24. Indeed, Matthew appears to be healthy. He eats well, plays basketball and engages in other exercise, attends school daily, and was able to take his state exams. He feels fine and has lost some weight (though he is still overweight for his age and height). He is scared.
25. There is mixed evidence concerning whether the nodules in Matthew's chest are benign or unrelated to his Ewing sarcoma. Ms. G. claimed that they had been present even before the mass in his neck was noticed, but his pediatrician's office was unable to locate any chest scans that had been done prior to 2017. Dr. Lee allowed as to how the nodules could possibly be from infection, but Matthew did not have signs of an active
lung infection, and if they were residual from prior infection—which Ms. G. testified that he previously had—they
would have decreased in size and number on the MSKCC scan, which they did not. While the April 21 CT scan done at Empire Imaging suggests that one nodule has disappeared, the radiologist did not have the benefit of the prior two scans from CHONY and MSKCC as comparatives. Overall, the Court finds the MSKCC scan and its conclusion of "possible" metastatic disease to be most persuasive.
26. Chemotherapy is, of course, an incredibly aggressive, painful, and risky treatment. Among the side effects are hair loss; nausea, vomiting, loss of appetite, and weight loss; mouth sores; pancytopenia (loss of red and white blood cells as well as platelets ), which could result the need for transfusions and which could be fatal; toxicity to the heart, kidneys, liver, or nervous system; growth impairment and/or other hormone deficiencies; permanent infertility; risk of secondary cancers, including leukemia ; and impact on adolescent lifestyle and education. Before beginning chemotherapy, Matthew, who is not even 14, has been advised by MSKCC to initiate sperm banking.
27. Were he to have chemotherapy, Matthew would have a central line inserted surgically for the medicine to be delivered intravenously. He would have cycles of chemotherapy every two weeks. He would come to the hospital or an oncology clinic for each treatment, and then go home in between treatments. The entire course would be approximately six to nine months in duration. The fact that the mass in his neck grew so slowly, and that the nodules in his lungs—if evidence of metastatic disease —have also grown slowly may have an unknown impact on his response to chemotherapy.
28. The Court does not find Ms. G.'s claims that neither Dr. Lee nor Dr. Meyers fully informed her of the side effects of chemotherapy to be credible. Pet. Ex. 1 contains Dr. Meyers's contemporaneous note in which he reported his full conversation with Ms. G. and Matthew concerning this issue.
29. The Court does credit that Ms. G. is a loving, attentive mother who has taken excellent care of her son throughout his life. She has been diligent in efforts to learn about his disease and get him the best possible care, even if she has been taken off a rational course most recently. Her motives are derived from love and are unchallenged.
Analysis
The protection of family life from state intervention is fundamental to ordered liberty. The fundamental right to parent one's child in the manner one sees fit is one of the most cherished in our society, provided special constitutional protection. Troxel v. Granville , 530 U.S. 57, 120 S.Ct. 2054, 147 L.Ed.2d 49 (2000) ; Santosky v. Kramer , 455 U.S. 745, 102 S.Ct. 1388, 71 L.Ed.2d 599 (1982) ; Wisconsin v. Yoder , 406 U.S. 205, 92 S.Ct. 1526, 32 L.Ed.2d 15 (1972) ; Pierce v. Society of Sisters , 268 U.S. 510, 45 S.Ct. 571, 69 L.Ed. 1070 (1925) ; Meyer v. Nebraska, 262 U.S. 390, 43 S.Ct. 625, 67 L.Ed. 1042 (1923) ; Bennett v. Jeffreys , 40 N.Y.2d 543, 387 N.Y.S.2d 821, 356 N.E.2d 277 (1976). It is only when a parent, through action or inaction, fails to provide the minimum degree of acceptable parenting, causing the child harm, that the state is permitted to exercise its parens patriae protective role. Prince v. Massachusetts , 321 U.S. 158, 64 S.Ct. 438, 88 L.Ed. 645 (1944).Even when the state intervenes in the family by seeking and obtaining an order of temporary custody (or "remand" as it is known in New York), parents are still vested with various rights, up to the moment their rights may be fully extinguished through involuntary termination-of-parental rights proceedings or voluntary surrender. Among other things, parents retain the right to make certain medical decisions for their children in foster care. While ACS typically takes over the right to make routine, prophylactic decisions as well as emergency ones, any important decision for which there is time to consider the options are reserved for parents, in the first instance. Thus, for example, the decision to consent to the administration of psychotropic medication belongs to the parent, Matter of Isaiah T.F.–C. , 136 A.D.3d 687, 23 N.Y.S.3d 914 (2d Dep't. 2016) ; Matter of Justin R. , 63 A.D.3d 1163, 881 N.Y.S.2d 305 (2d Dep't. 2009) ; Matter of Martin F. , 13 Misc. 3d 659, 820 N.Y.S.2d 759 (Fam. Ct. Monroe Co. 2006), as does the right to consent to using the child's name and image in a documentary film, Matter of Erica A. , 37 Misc. 3d 639, 946 N.Y.S.2d 455 (Fam. Ct. Bronx Co. 2012).
This parental decision-making authority can be overridden by ACS for children in its temporary custody, but if the parent objects, a hearing is required. Isaiah T.F.–C. , 136 A.D.3d at 688, 23 N.Y.S.3d 914. In this case, ACS does not seek to remove the child from his mother, but does seek an order temporarily transferring medical decision-making authority from her.
Family Court has statutory authority grant such an order following a hearing, pursuant to Family Court Act §§ 1027 and 233. While more typically used to determine the need for a removal of a child, § 1027 provides that when a child has not been removed from his parent's care, the petitioner may seek a hearing "to determine whether the child's interests require protection... pending a final order of disposition." There is no particular statutory limit placed on what the protective order may include. Section 233 provides: "Whenever a child within the jurisdiction of the court appears to the court to be in need of medical, surgical, therapeutic, or hospital care or treatment, a suitable order may be made therefore." Taken together, these provisions vest in Family Court the authority to grant the type of order ACS is requesting here, following a hearing.
As a threshold matter, to prevail at such a hearing, petitioner must demonstrate that the child would be at imminent risk of harm otherwise, a harm that outweighs the harm of non-intervention. Family Court Act § 1027(b) ; c.f. Nicholson v. Scoppetta , 3 N.Y.3d 357, 787 N.Y.S.2d 196, 820 N.E.2d 840 (2004). This is because the child is not in ACS's care at the present time, and before any custodial-like powers can be exercised on the child's behalf, due process requires this level of harm to be established.
Establishing imminent risk of harm, while necessary, is not sufficient for an agency to obtain a court order granting it the authority to override a parent's objection to chemotherapy for her child. The standard at this hearing must necessarily be the same as an Isaiah T.F.–C. hearing, to wit: whether there is clear and convincing evidence that the proposed treatment plan for the child to which ACS intends to consent is narrowly tailored to give substantive effect to the child's liberty interest, taking into account all relevant factors, including the child's best interests; the benefits to be gained from the treatment; the adverse side effects; and whether any less intrusive treatments are available. Id. ; Justin R. , 63 A.D.3d at 1163, 881 N.Y.S.2d 305.In weighing these factors, "great deference must be accorded a parent's choice as to the mode of medical treatment to be undertaken and the physician selected to administer the same." Matter of Hofbauer , 47 N.Y.2d 648, 419 N.Y.S.2d 936, 393 N.E.2d 1009 (1979). It is acceptable for a parent to rely on the advice and competency of a physician who is licensed to practice medicine in New York State. Id. at 655, 419 N.Y.S.2d 936, 393 N.E.2d 1009. Ultimately, the most significant factor is whether the parents have provided a medically acceptable alternative to the state's proposed treatment. Courts should not "assume the role of a surrogate parent and establish as the objective criteria with which to evaluate a parent's decision its own judgment as to the exact method or degree of medical treatment which should be provided." Id. at 656, 419 N.Y.S.2d 936, 393 N.E.2d 1009. As long as the parent's proposed plan is endorsed by a licensed physician in New York and "has not been totally rejected by all medical authority," the state generally does not have a basis for intervention on child protection grounds. Id. ; c.f. Weber v. Stony Brook Hospital , 95 A.D.2d 587, 467 N.Y.S.2d 685 (2d Dep't. 1983).
While Hofbauer is a jurisdictional case that resulted in the dismissal of neglect charges in their entirety, its reasoning has application to the context of a §§ 1027/233 hearing like the one here. First, it should be noted that Weber applied Hofbauer in the context of an emergency hearing not unlike this one. Moreover, if the evidence at a §§ 1027/233 hearing does not even support a valid cause of action for child maltreatment (albeit the evidence was admitted on a looser basis than at a fact-finding hearing, and with limited discovery practice), then a court would err in granting the significant relief contemplated here. Put another way, it would be an injustice to order chemotherapy now only to dismiss the case entirely later for lack of jurisdiction.
Here, ACS has established that Matthew would be at imminent risk of harm should he not receive immediate cancer treatment, a harm that far outweighs the very real harm of the chemotherapy itself. Imminence in this context does not require tragedy to strike; courts can step in sooner than that. Given the way cancer works, by the time the risk is visible in the form of an obvious tumor, the patient's chances of survival are far lower.
Moreover, there is clear and convincing evidence that Matthew has Ewing sarcoma, a deadly cancer that perniciously targets children; that he has already had surgery to excise the tumor in his neck ; that the standard treatment at this point is systemic chemotherapy plus radiation; that the survival rate is much higher if he has this treatment right now rather than waiting for another tumor to appear; that the chance of recurrence is 95 percent; and that the chance of survival without treatment is less than 10 percent. There is also clear and convincing evidence that the side effects of chemotherapy are horrible to contemplate for a boy of Matthew's age, debilitating to even the strongest (emotionally and physically) adult, and, in rare cases, fatal in itself. Plus, it might not work; Matthew could have chemotherapy and still die of Ewing sarcoma. Finally, there is clear and convincing evidence that there is no other treatment that could work.
Much was made at the hearing concerning whether or not Matthew's cancer was local or metastatic. In the end, it does not matter. The standard treatment for local or metastatic Ewing sarcoma is the same: immediate chemotherapy. Assuming that it is local, the record at this hearing demonstrates that it is simply not rational for Ms. G. to hope that Matthew is in the lucky 5 percent of patients whose cancer does not recur after the local mass is excised. Her irrational decision-making was evident from her claim that her natural remedies would lead to a "90 percent sure" cure. Given how much harder it will be to actually cure Matthew with chemotherapy if he is untreated now and the cancer shows up again later, it is objectively unreasonable not to initiate treatment now.
Assuming that Dr. Lee is correct and the nodules on Matthew's lungs are evidence of metastatic Ewing sarcoma, it is still unreasonable not to commence treatment immediately, even if the survival rate is at best 30 percent. Counsel for mother and child argue that the survival rate doing nothing is as high as 10 percent and with chemotherapy it is as low as 15 percent; given the powerful side effects of chemotherapy, they argue that it is not unreasonable parenting to judge that this five percent differential is not worth it. But the facts as determined at this hearing are that the survival rate doing nothing is less than 10 percent, and survival with treatment ranges from 15 to 30 percent. There are ranges on both ends. There is no evidence to support a "probability of probabilities" analysis as applied to Matthew's case.
The bottom line is that there is simply no other treatment that has any possibility of curing Matthew, and as invasive and life-altering as chemotherapy is, the risk of doing nothing is too stark compared to the upside, as uncertain as the benefit may be. The evidence is clear and convincing that, in the absence of a medically acceptable alternative that is proven to be even somewhat efficacious, authority must be transferred to ACS for the purpose of consenting to the standard chemotherapy treatment and related medical decision-making. Ms. G. has had almost three months since receiving the original diagnosis to develop a viable alternative plan, but despite her sincere love and diligent efforts, she has not been able to do so.
The Court has considered the fear that confronts Matthew and his sincere desire to have a normal childhood, as well as the genuine love and affection his mother has for him. She does not want to see him go through the ravages of chemotherapy, especially if it doesn't work. The reality, however, is that it is almost entirely certain that there are microscopic cancer cells in his body right now, poised to rob him of more than just his childhood.
THEREFORE, IT IS HEREBY ORDERED THAT:
1. Medical decision-making authority regarding the cancer treatment for Matthew V. (DOB xxxxx/2003), and related medical issues, is hereby temporarily vested in the Commissioner of ACS, pending further order of the Court or ending of Court jurisdiction in this matter, whichever comes first.
2. In exercising its medical decision-making authority, ACS shall consult Matthew's mother, Lynette G., as well as Matthew, in an age-appropriate manner. In particular, consideration shall be given to:
a. Ms. G.'s preference for provider.
b. Matthew's education and the need to maintain as much normalcy of adolescence as possible under the circumstances.
c. Other factors identified by Ms. G. and Matthew as important to them.
3. Where there are choices in Matthew's treatment for which there is no scientific or medical reason to favor one choice over another, ACS shall defer to the family's choice to the greatest extent feasible under the circumstances.
4. ACS shall ensure that Matthew receives individual counseling from a licensed mental health professional experienced
in pediatric oncology and related issues.
5. ACS shall ensure that Matthew is enrolled in a peer support group for adolescents who are experiencing cancer.
6. ACS shall ensure that Ms. G. is referred to individual counseling with a licensed mental health professional experienced in pediatric oncology and related issues.
7. ACS shall ensure that Ms. G. is referred to a support group for parents whose children have, or have had, cancer.
8. To afford Ms. G. and the attorney for the child the opportunity to seek appellate review of this order, enforcement of this order is hereby stayed until 5pm on Monday, May 1, 2017. Absent a further stay from a court of competent jurisdiction, this order shall take effect at that time. Nothing shall prohibit Matthew from commencing chemotherapy treatment prior to that date and time if he and his mother signal their intent not to appeal.
9. Notwithstanding the terms of paragraph 8, ACS shall immediately make arrangements for Matthew's treatment so that
it may commence as soon as possible in the event that enforcement of this order is not stayed beyond May 1 at 5pm.
After this decision and order were issued, Ms. G. brought Matthew for treatment to a third hospital. By the time his treatment commenced in May 2017, additional nodules had been detected on his lungs. Following intensive chemotherapy and radiation therapy, in February 2018 Matthew's doctors declared him to be cancer-free and in remission.
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