Doctors are experts on the dying process. Their education doesn't take years. I suspect they learn more about the dying process in less time than it takes to learn the basics of their profession. So why do they put off The Conversation and knowingly perform unnecessary and unwanted treatment? Most of which occurs at the end of life.
Jonathan Rauch in his May, 2013 article for The Atlantic, "How Not To Die", provides several interconnected reasons. In American medical training we instill in our prospective physicians a 'war on death'. Rauch says, "Unwanted treatment is a particularly confounding problem because it is not a product of malevolence but a by-product of two strengths of American medical culture: The system's determination to save lives, and its technological virtuosity." Doctors who come here from India have marveled at the technological resources available to them but at the same time see serious shortcomings in patient/doctor interaction. Where medical training is not as technologically available patient/doctor communication is very important for hands on diagnosis and treatment. Encompassing this communication may entail The Conversation. U. S. trained doctors know about The Conversation and also know when their patients are dying, but they are not good at telling the patient and his family or don't even use it as part of their practice. When it is used it should be, explained '… patiently and in plain English, his condition and his treatment options, to learn what his goals were for the time he had left, and to establish how much and what kind of treatment he really desired.'
Albert Mulley, addresses the war on death as applied to those knowingly dying, "Sometimes you block the near exits, and all you've got left is a far exit, which is not a dignified and comfortable death."
Rauchs article features a doctor Angelo Volandes and his efforts to bring The Conversation into the patient /doctor treatment protocol. It has made a small, very small penetration. I have left out a significant portion of this article so if you want to know more go here.