Human-in-the-Loop Multi-Agent Ventilator Decision Support with Contextual Bandit Preference Learning

Mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS) requires balancing competing physiological goals, including oxygenation, lung protection, and acid-base homeostasis. However, current data-driven methods, especially those imitating retrospective Electronic Health Records (EHR), often suffer from imitation bias. They may capture superficial correlations from inconsistent clinical demonstrations, such as associating passive ventilator settings with survival because such settings are common in stable patients, and thus fail to generalize to volatile or out-of-distribution phenotypes. Standard Reinforcement Learning (RL) methods also struggle with the adversarial trade-offs of critical care and often produce opaque policies with limited clinical interpretability. To address these limitations, we introduce VentAgent, a hierarchical framework in which Large Language Models (LLMs) act as transparent arbitrators for mechanical ventilation. We reformulate ventilation control as a dynamic Multi-Objective Arbitration process rather than single-objective optimization. VentAgent decomposes decision-making into three interpretable stages: Perception, Planning, and Orchestration. By leveraging the semantic reasoning capabilities of LLMs, it synthesizes strategies from heterogeneous experts and resolves conflicting clinical priorities through an explicit coordination mechanism. Evaluations on a high-fidelity physiological simulator show that VentAgent outperforms state-of-the-art RL and classical control baselines. Moreover, it converts control decisions into human-readable reasoning chains, offering a safer, more interpretable, and adaptable paradigm for critical care automation.

The use of Large Language Models (LLMs) across diverse areas of human activity-ranging from everyday tasks to safety-critical applications-aims to enhance decision-making effectiveness with minimal human feedback. Concurrently, it seeks to align decisions with human expectations, preferences, and needs while mitigating risks associated with AI non-determinism. However, humans frequently over- or under-rely on AI recommendations, and current AI systems remain poorly calibrated to human expectations. To address these challenges, we introduce a human-AI collaborative decision-making framework designed to augment human capabilities and align AI agents with human preferences and expectations. Specifically, this paper (a) formulates the collaborative decision-making task as a stochastic game between an AI agent and a human player, and (b) proposes the Human-Centric Reflective Architecture (HCRA), which integrates human-calibrated models with reinforcement learning agents that leverage linguistic feedback in an iterative, reflective process. Evaluation results demonstrate that HCRA enhances decision-making effectiveness and delivers high-quality recommendations.

Clinical decision support AI systems (CDSASs) must adapt to evolving patient conditions in real-time while adhering to strict safety constraints. We present an online adaptive framework that integrates Treatment Effect (TE) estimation to quantify clinical benefits, a patient Digital Twin (DT) to simulate treatment trajectories, and Reinforcement Learning (RL) for sequential decision-making. The AI system is initially trained on historical medical records and operates in a continuous learning loop. To ensure safety, a rule-based module monitors vital signs and blocks contraindicated treatments. Cases with strong internal model disagreement are flagged for clinician review, simulated in our experiments via a pre-trained outcome model. We validate our framework using both a synthetic clinical simulator and a real-world ovarian cancer dataset from The Cancer Genome Atlas (TCGA). In both simulated and clinical settings, our method demonstrated superior effectiveness and stability in recommending treatments compared to standard computational baselines. Furthermore, the AI system maintains low latency and requires expert consultation for only a minority of cases in our experimental validation, demonstrating its potential as a safe, clinician-supervised tool for personalized medicine that continuously improves through practical use.