Learning Preference-Based Objectives from Clinical Narratives for Dynamic Sepsis Treatment

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.