arXiv:2604.10783v2 Announce Type: replace Abstract: Designing reward functions for reinforcement learning (RL) in healthcare remains challenging because clinically meaningful outcomes are sparse, delayed, and difficult to explicitly specify. Although structured clinical data capture physiologic states, they often fail to reflect broader aspects of patient trajectories such as treatment response, recovery dynamics, and intervention burden. Clinical narratives, by contrast, encode longitudinal clinician assessments of disease progression, treatment effectiveness, and recovery, providing a potential source of trajectory-level supervision beyond predefined outcome metrics. We propose Clinical Narrative-informed Preference Rewards (CN-PR), a framework that learns reward functions directly from discharge summaries by treating clinical narratives as scalable supervision for trajectory-level preferences. Using a large language model, we derive trajectory quality scores and construct pairwise preferences between patient trajectories to learn rewards through preference-based optimization. To account for variability in narrative informativeness, we incorporate a task relevance signal that weights supervision according to its relevance to the downstream decision-making task. We evaluate CN-PR in dynamic sepsis treatment using offline RL. The learned reward demonstrated strong monotonic alignment with trajectory quality scores and produced policies associated with improved recovery-related outcomes, including increased organ support-free days and faster shock resolution, while maintaining mortality performance comparable to outcome-based reward baselines. These findings were preserved under external validation. Our results suggest that clinical narratives provide a scalable and expressive source of supervision for reward learning in dynamic treatment regimes.

arXiv:2510.08350v3 Announce Type: replace-cross Abstract: Objective: Enteral nutrition (EN) delivery in the ICU remains suboptimal due to limited personalization and uncertainty regarding appropriate calorie, protein, and fluid targets under dynamic metabolic demands. We introduce DeepEN, a reinforcement learning (RL) framework for personalized EN optimization using electronic health record data. Methods: DeepEN was trained on over 11,000 ICU patients from MIMIC-IV to generate 4-hourly, patient-specific caloric, protein, and fluid targets. The state representation incorporated demographics, comorbidities, vital signs, laboratory values, and recent interventions. A physiologically aligned reward framework balanced biomarker stability with long-term survival. Policy learning employed a dueling double deep Q-network with Conservative Q-Learning regularization to enable safe offline training. Results: DeepEN achieved the highest estimated policy value ($V^\pi = 9.48$) and the lowest calibrated mortality (18.8 +/- 1.0%), representing a 4.0 percentage-point absolute reduction compared with clinician practice (22.8%). The policy also demonstrated superior metabolic stability, achieving the highest proportion of glucose, phosphate, and sodium values within target range. Furthermore, deviation from the DeepEN policy was independently associated with increased mortality and biomarker instability, whereas deviation from a random policy showed no such association. Interpretability analyses further indicated that recommendations were conditioned on physiologically relevant markers of organ function and metabolic status rather than static dosing heuristics. Conclusion: DeepEN demonstrates the feasibility of conservative offline RL for safe, individualized EN optimization, highlighting the potential of data-driven personalization to complement guideline-based approaches in critical care.