Spousal bereavement severely deteriorates mental health. While palliative care benefits dying patients, its "stress-buffering" effect on survivors' depression remains empirically elusive due to acute small-$N$ constraints in longitudinal dyadic data. This study evaluates the causal impact of palliative care on bereaved spouses while introducing Synthetic Data Generation (SDG) to resolve sample attrition in quasi-experimental designs. Using SHARE panel data, we augment the sparse treated cohort via a Conditional Tabular GAN, anchoring synthetic trajectories to empirical baseline constraints to preserve causal pathways. A Matched Difference-in-Differences estimator applied to the high-fidelity augmented dataset evaluates the treatment effect. Results reveal a non-linear psychological response. Palliative care initially exacerbates acute depressive symptoms at the time of loss ($β_0 = 0.218,\ p < 0.05$), reflecting the intense emotional confrontation of the intervention. However, a sustained stress-buffering effect emerges in subsequent periods ($β_2 = -0.763,\ p < 0.01$), indicating an accelerated long-term recovery compared to standard care. Estimates are highly robust to unob
While palliative care is increasingly commonly delivered to hospitalized patients with serious illnesses, few studies have estimated its causal effects. Courtright et al. (2016) adopted a cluster-randomized stepped-wedge design to assess the effect of palliative care on a patient-centered outcome. The randomized intervention was a nudge to administer palliative care but did not guarantee receipt of palliative care, resulting in noncompliance (compliance rate ~30%). A subsequent analysis using methods suited for standard trial designs produced statistically anomalous results, as an intention-to-treat analysis found no effect while an instrumental variable analysis did (Courtright et al., 2024). This highlights the need for a more principled approach to address noncompliance in stepped-wedge designs. We provide a formal causal inference framework for the stepped-wedge design with noncompliance by introducing a relevant causal estimand and corresponding estimators and inferential procedures. Through simulation, we compare an array of estimators across a range of stepped-wedge designs and provide practical guidance in choosing an analysis method. Finally, we apply our recommended metho
Bias and inequity in palliative care disproportionately affect marginalised groups. Large language models (LLMs), such as GPT-4o, hold potential to enhance care but risk perpetuating biases present in their training data. This study aimed to systematically evaluate whether GPT-4o propagates biases in palliative care responses using adversarially designed datasets. In July 2024, GPT-4o was probed using the Palliative Care Adversarial Dataset (PCAD), and responses were evaluated by three palliative care experts in Canada and the United Kingdom using validated bias rubrics. The PCAD comprised PCAD-Direct (100 adversarial questions) and PCAD-Counterfactual (84 paired scenarios). These datasets targeted four care dimensions (access to care, pain management, advance care planning, and place of death preferences) and three identity axes (ethnicity, age, and diagnosis). Bias was detected in a substantial proportion of responses. For adversarial questions, the pooled bias rate was 0.33 (95% confidence interval [CI]: 0.28, 0.38); "allows biased premise" was the most frequently identified source of bias (0.47; 95% CI: 0.39, 0.55), such as failing to challenge stereotypes. For counterfactual s
The transition of end-of-life care to palliative care (PC) sparks intense debate: does it provide economic relief or shift unremunerated labor costs onto families? Evaluating this is hindered by causal inference challenges and skewed healthcare costs. To overcome these limitations, we introduce a Synthetic Data Generation framework. Using pan-European SHARE data (2016-2021), we deploy Tabular Denoising Diffusion Probabilistic Models within a Two-Learner architecture to synthesize high-fidelity digital twins. By including the 2020-2021 lockdowns, we leverage the COVID-19 pandemic to isolate structural inequalities from transient market shocks. Our findings challenge the strict cost-shifting hypothesis: on average, PC acts as a "double shield", truncating out-of-pocket expenditures (financial toxicity) and informal caregiving shadow values (time poverty). However, quantile treatment models expose a "broken shield" for vulnerable households and severe tail events. Non-cancer trajectories drive massive structural penalties that escalate at the distribution's tail, mechanically compounded by physical dependency. Socio-demographics heavily modulate this exposure: lacking a spousal net in
Effective communication in serious illness and palliative care is essential but often under-taught due to limited access to training resources like standardized patients. We present PAL (Palliative Assisted Learning-bot), a conversational system that simulates emotionally nuanced patient interactions and delivers structured feedback grounded in an existing empathy-based framework. PAL supports text and voice modalities and is designed to scaffold clinical skill-building through repeated, low-cost practice. Through a mixed-methods study with 17 U.S. medical trainees and clinicians, we explore user engagement with PAL, evaluate usability, and examine design tensions around modalities, emotional realism, and feedback delivery. Participants found PAL helpful for reflection and skill refinement, though some noted limitations in emotional authenticity and the adaptability of feedback. We contribute: (1) empirical evidence that large language models can support palliative communication training; (2) design insights for modality-aware, emotionally sensitive simulation tools; and (3) implications for systems that support emotional labor, cooperative learning, and AI-augmented training in hi
Background: Incidence of adverse outcome events rises as patients with advanced illness approach end-of-life. Exposures that tend to occur near end-of-life, e.g., use of wheelchair, oxygen therapy and palliative care, may therefore be found associated with the incidence of the adverse outcomes. We propose a strategy for time-to-event analysis to mitigate the time-varying confounding. Methods: We propose a concept of reverse time-to-death (rTTD) and its use for the time-scale in time-to-event analysis. We used data on community-based palliative care uptake (exposure) and emergency department visits (outcome) among patients with advanced cancer in Singapore to illustrate. We compare the results against that of the common practice of using time-on-study (TOS) as time-scale. Results: Graphical analysis demonstrated that cancer patients receiving palliative care had higher rate of emergency department visits than non-recipients mainly because they were closer to end-of-life, and that rTTD analysis made comparison between patients at the same time-to-death. Analysis of emergency department visits in relation to palliative care using TOS time-scale showed significant increase in hazard ra
Objectives: Prior event rate ratio (PERR) is a method shown to perform well in mitigating confounding in real-world evidence research but it depends on several model assumptions. We propose an analytic strategy to correct biases arising from violation of two model assumptions, namely, population homogeneity and event-independent treatment. Study Design and Setting: We reformulate PERR estimation by embedding a treatment-by-period interaction term in an analytic model for recurrent event data, which is robust to bias arising from unobserved heterogeneity. Based on this model, we propose a set of methods to examine the presence of event-dependent treatment and to correct the resultant bias. We evaluate the proposed methods by simulation and apply it to a de-identified dataset on palliative care and emergency department visits in patients with advanced cancer. Results: Simulation results showed that the proposed method could mitigate the two sources of bias in PERR. In the palliative care study, analysis by the Cox model showed that patients who had started receiving palliative care had higher incidence of emergency department visits than their match controls (hazard ratio 3.31; 95% c
Effective patient-provider communication is crucial in clinical care, directly impacting patient outcomes and quality of life. Traditional evaluation methods, such as human ratings, patient feedback, and provider self-assessments, are often limited by high costs and scalability issues. Although existing natural language processing (NLP) techniques show promise, they struggle with the nuances of clinical communication and require sensitive clinical data for training, reducing their effectiveness in real-world applications. Emerging large language models (LLMs) offer a new approach to assessing complex communication metrics, with the potential to advance the field through integration into passive sensing and just-in-time intervention systems. This study explores LLMs as evaluators of palliative care communication quality, leveraging their linguistic, in-context learning, and reasoning capabilities. Specifically, using simulated scripts crafted and labeled by healthcare professionals, we test proprietary models (e.g., GPT-4) and fine-tune open-source LLMs (e.g., LLaMA2) with a synthetic dataset generated by GPT-4 to evaluate clinical conversations, to identify key metrics such as `und
In this paper we introduce novel Virtual Reality (VR) and Augmented Reality (AR) treatments to improve the psychological well being of patients in palliative care, based on interviews with a clinical psychologist who has successfully implemented VR assisted interventions on palliative care patients in the Hong Kong hospital system. Our VR and AR assisted interventions are adaptations of traditional palliative care therapies which simultaneously facilitate patients communication with family and friends while isolated in hospital due to physical weakness and COVID-19 related restrictions. The first system we propose is a networked, metaverse platform for palliative care patients to create customized virtual environments with therapists, family and friends which function as immersive and collaborative versions of 'life review' and 'reminiscence therapy'. The second proposed system will investigate the use of Mixed Reality telepresence and haptic touch in an AR environment, which will allow palliative care patients to physically feel friends and family in a virtual space, adding to the sense of presence and immersion in that environment.
As digital health solutions continue to reshape healthcare delivery, telehealth software applications have become vital for improving accessibility, continuity of care, and patient outcomes. This paper presents an analysis of designing a software application focused on Enhanced Telehealth Capabilities (ETHC) for palliative care, integrating across three socio-technical dimensions: quality, human values, and real-world. Designing for quality attributes -- such as performance, maintainability, safety, and security -- ensured that the system is technically robust and compliant with clinical standards. Designing for human values -- empathy, inclusivity, accessibility, and transparency -- helped enhance patient experience, trust, and ethical alignment. Designing for real-world -- through a multidisciplinary, experience-based co-design approach involving clinicians, patients, and carers that guided iterative cycles of prototyping, usability testing, and real-world evaluation -- ensured continuous refinement of features and alignment with clinical practice. The resulting telehealth software solution demonstrated that our socio-technical design framework was successful in producing a secur
Improving the quality of end-of-life care for hospitalized patients is a priority for healthcare organizations. Studies have shown that physicians tend to over-estimate prognoses, which in combination with treatment inertia results in a mismatch between patients wishes and actual care at the end of life. We describe a method to address this problem using Deep Learning and Electronic Health Record (EHR) data, which is currently being piloted, with Institutional Review Board approval, at an academic medical center. The EHR data of admitted patients are automatically evaluated by an algorithm, which brings patients who are likely to benefit from palliative care services to the attention of the Palliative Care team. The algorithm is a Deep Neural Network trained on the EHR data from previous years, to predict all-cause 3-12 month mortality of patients as a proxy for patients that could benefit from palliative care. Our predictions enable the Palliative Care team to take a proactive approach in reaching out to such patients, rather than relying on referrals from treating physicians, or conduct time consuming chart reviews of all patients. We also present a novel interpretation technique
Palliative medicine is an interdisciplinary specialty focusing on improving quality of life (QOL) for patients with serious illness and their families. Palliative care programs are available or under development at over 80% of large US hospitals (300+ beds). Palliative care clinical trials present unique analytic challenges relative to evaluating the palliative care treatment efficacy which is to improve patients diminishing QOL as disease progresses towards end of life (EOL). A unique feature of palliative care clinical trials is that patients will experience decreasing QOL during the trial despite potentially beneficial treatment. Often longitudinal QOL and survival data are highly correlated which, in the face of censoring, makes it challenging to properly analyze and interpret longitudinal QOL trajectory. To address these issues, we propose a novel semiparametric statistical approach to jointly model longitudinal QOL and survival data. There are two sub-models in our approach: a semiparametric mixed effects model for longitudinal QOL and a Cox model for survival. We use regression splines method to estimate the nonparametric curves and AIC to select knots. We assess the model t
Extracting clinical information from medical transcripts in low-resource languages remains a significant challenge in healthcare natural language processing (NLP). This study evaluates a two-step pipeline combining Aya-expanse-8B as a Persian-to-English translation model with five open-source small language models (SLMs) -- Qwen2.5-7B-Instruct, Llama-3.1-8B-Instruct, Llama-3.2-3B-Instruct, Qwen2.5-1.5B-Instruct, and Gemma-3-1B-it -- for binary extraction of 13 clinical features from 1,221 anonymized Persian transcripts collected at a cancer palliative care call center. Using a few-shot prompting strategy without fine-tuning, models were assessed on macro-averaged F1-score, Matthews Correlation Coefficient (MCC), sensitivity, and specificity to account for class imbalance. Qwen2.5-7B-Instruct achieved the highest overall performance (median macro-F1: 0.899; MCC: 0.797), while Gemma-3-1B-it showed the weakest results. Larger models (7B--8B parameters) consistently outperformed smaller counterparts in sensitivity and MCC. A bilingual analysis of Aya-expanse-8B revealed that translating Persian transcripts to English improved sensitivity, reduced missing outputs, and boosted metrics ro
In many domains such as Palliative Care, Credit Assignment and Recommender Systems, predictions may causally influence the outcomes they predict. This phenomena is known as Outcome Performativity. This paper formalises an approach for detecting Outcome Performativity using prediction intervention called Outcome Performativity A/B Detection (OPAB). OPAB enables the detection of Outcome Performativity by assessing the dissimilarity in outcome distributions produced by different predictions groups (interventions). If that dissimilarity is significant, Outcome Performativity is detected. We derive sample complexity bounds for OPAB under various Outcome Performative assumption classes which we empirically validate. Results show that detecting Outcome Performativity using OPAB is achievable in numerous cases. Results also show the presence of regions of indistinguishability which describe settings where the allotted number of interventions are insufficient for detecting Outcome Performativity. The results of which have broader practical implications for the detectability of Outcome Performativity in settings where samples are scarce, cost-prohibitive or potentially unethical to obtain. T
Generative artificial intelligence redefines higher education by restructuring the processes through which scientific knowledge is produced and validated. These systems are not neutral; they actively contribute to the marginalization of non-hegemonic epistemologies. This research draws upon educational sciences, critical technology studies, and disability studies to demonstrate that training datasets, which remain predominantly Anglophone and Western-centric, reinforce epistemic coloniality. The situation of persons with disabilities provides a particularly clear illustration of this phenomenon. Technological architectures frequently confine these individuals to reductive stereotypes or exclude them from the design process, leading to a double marginalization. This article examines whether a hybridization between the researcher and the machine might preserve epistemic plurality, while acknowledging the structural limitations inherent in algorithmic correction when used as a purely palliative strategy.
Building and deploying machine learning solutions in healthcare remains expensive and labor-intensive due to fragmented preprocessing workflows, model compatibility issues, and stringent data privacy constraints. In this work, we introduce an Agentic AI framework that automates the entire clinical data pipeline, from ingestion to inference, through a system of modular, task-specific agents. These agents handle both structured and unstructured data, enabling automatic feature selection, model selection, and preprocessing recommendation without manual intervention. We evaluate the system on publicly available datasets from geriatrics, palliative care, and colonoscopy imaging. For example, in the case of structured data (anxiety data) and unstructured data (colonoscopy polyps data), the pipeline begins with file-type detection by the Ingestion Identifier Agent, followed by the Data Anonymizer Agent ensuring privacy compliance, where we first identify the data type and then anonymize it. The Feature Extraction Agent identifies features using an embedding-based approach for tabular data, extracting all column names, and a multi-stage MedGemma-based approach for image data, which infers
We introduce MentalChat16K, an English benchmark dataset combining a synthetic mental health counseling dataset and a dataset of anonymized transcripts from interventions between Behavioral Health Coaches and Caregivers of patients in palliative or hospice care. Covering a diverse range of conditions like depression, anxiety, and grief, this curated dataset is designed to facilitate the development and evaluation of large language models for conversational mental health assistance. By providing a high-quality resource tailored to this critical domain, MentalChat16K aims to advance research on empathetic, personalized AI solutions to improve access to mental health support services. The dataset prioritizes patient privacy, ethical considerations, and responsible data usage. MentalChat16K presents a valuable opportunity for the research community to innovate AI technologies that can positively impact mental well-being. The dataset is available at https://huggingface.co/datasets/ShenLab/MentalChat16K and the code and documentation are hosted on GitHub at https://github.com/ChiaPatricia/MentalChat16K.
Objectives: Prior event rate ratio (PERR) is a promising approach to control confounding in observational and real-world evidence research. One of its assumptions is that occurrence of outcome events does not influence later event rate, or in other words, absence of 'event dependence'. This study proposes, evaluates and illustrates a bias reduction method when this assumption is violated. Study Design and Setting: We propose the conditional frailty method for implementation of PERR in the presence of event dependence and evaluate its performance by simulation. We demonstrate the use of the method with a study of emergency department visit rate and palliative care in patients with advanced cancer in Singapore. Results: Simulations showed that, in the presence of negative (positive) event dependence, the crude PERR estimate of treatment effect was biased towards (away from) the null value. The proposed method successfully reduced the bias, with median of absolute level of relative bias at about 5%. Dynamic random-intercept modelling revealed positive event dependence in emergency department visits among patients with advanced cancer. While conventional time-to-event regression analys
Degradation of joint cartilages can result in osteoarthritis (OA) affecting about 10\% of the US population and responsible for significant hospitalization costs. While observations show that low dose radiation treatments (LDRT) bring improvements for a majority of OA patients, the underlying mechanism is not sufficiently understood. Here, we show how the radiation enhanced diffusion (RED) can boost the molecular transport in cartilages promoting cartilage self-healing rendering a mechanism for the observed positive LDRT effects on OA. Along with quantitative estimates for RED, we predict a related phenomenon of the electric charge build up that allows LDRT schedules promoting desirable types of molecular transports dominated by either positive or negative molecular species. Our analyses call upon further experimental verifications and clinical trials with curative rather than palliative intent. In addition to OA applications, our developed approaches can be useful for sports medicine dealing with damage or degeneration of the articular cartilages.
In France, government protection of unaccompanied minors (UMs) depends upon the recognition of their minority status and often result in a rejection. A significant proportion of UMs therefore find themselves unprotected. This qualitative study explores the contextual and individual factors that shape the physical and mental health needs of unprotected UMs in Paris. Interviews were conducted with UMs (n=12) and those working with them (n=36). A deductive-inductive thematic analysis was carried out. The study contributes to the analysis of the health determinants of unprotected UMs. It shows that institutional barriers limit the scope for action by civil society in the palliative care they receive. The consequence for them is living in conditions of instability and precariousness, with very little prospects for the future, which has a negative impact on their physical and mental health.