An altar at the writer's home of her grandmother Lupe. Credit: Azucena Rasilla

On Sunday, April 2, 2022, I received a frantic call from my mom letting me know that grandma Lupe had fallen ill and I needed to go to my parents’ house to check on her. 

Getting those types of calls had become a regular occurrence. Since the fall of 2020, grandma’s health had deteriorated due to age and, I am certain, two years of stress, uncertainty, and loneliness caused by the pandemic. As part of The Oaklandside’s pandemic coverage, I’ve shared personal essays chronicling how my family and I kept her safe from contracting COVID-19. 

Since 2014, grandma had been in and out of the hospital due to an ongoing series of strokes, including a hemorrhagic stroke in 2015, and she was left with a condition called Broca’s aphasia, a loss of language. The aphasia affects the left part of the brain in charge of speech, comprehension, and writing.

A few months before grandma fell ill, my family decided that it was time to purchase a funeral and cemetery package. It had been offered to my mom in monthly payments as a payment plan—the down payment cost close to $2,000, and the monthly payments roughly $400 a month. The cremation package alone (my grandma’s wish) was almost $7,000. The total package that we signed up for was $16,250. 

Dying isn’t cheap, and it’s only getting more expensive. According to the National Funeral Directors Association, the median cost of a funeral with cremation has increased more than 11% over the past five years, to about $7,000. We knew that when the time came, having a plan already in place would be easier than trying to come up with that kind of cash, all at once.

end of life planning resources

  1. Click here to access California’s Advance Health Care Directive
  2. California Department of Public Health offers a database of hospice facilities
  3. Hospice care information through Medicare, the Veterans’ Administration (VA), and Medicaid
  4. How to obtain a death certificate through the Alameda County Public Health Department’s vital registration department
  5. The Consumer Guide to Funeral and Cemetery Purchases, published by the California Department of Consumer Affairs’ Cemetary and Funeral Bureau
  6. Oakland author Jessica Mitford’s book, The American Way of Death, an exposé of the U.S. funeral industry and its predatory practices toward grieving families

The day after grandma got sick, she went into the emergency room and was sent home with medication to treat a urinary tract infection. Two days later, she was back in the hospital. By that Friday, her condition had deteriorated and she was suffering from complications from the UTI, and pneumonia in her left lung from aspiration, which occurs when food, saliva, liquids, or vomit reach your lungs instead of passing through the esophagus and into the stomach.

By Friday, the medical team notified us that grandma had entered the dying stage, and we needed to decide how we wanted her to transition. 

In 2019, my mom, sister (a neuro nurse practitioner), and I sat down with grandma to go over her wishes for when she was no longer able to make medical decisions for herself. In California,  a two-part document called an Advance Health Care Directive is required to appoint someone to make health care decisions on your behalf, including when to provide, withhold, or withdraw medical treatment and pain relief. The form needs to either be signed in front of two witnesses (unrelated by blood to the individual) or notarized. A copy of the form should be kept with the person’s belongings, and one should be turned over to their medical provider. 

When we filled out the advance directive, grandma made it clear that she wanted to die at home and not in a hospital. She didn’t want to be resuscitated or kept alive artificially. 

Writer Azucena Rasilla with her grandmother. Credit: Azucena Rasilla

In keeping with her instructions, that Friday at the hospital, my mom, sister, and I opted for “comfort care”—an approach that prioritizes pain mitigation over invasive or painful medical interventions—and requested that hospice, or end-of-life care, be delivered at grandma’s home. According to the National Hospice and Palliative Care Association, more than half of Medicare beneficiaries received one or more days of hospice care in 2019. 

Government programs like Medicare, the Veterans’ Administration (VA), and Medicaid offer coverage for hospice care. Private insurance plans may or may not cover hospice care, and holders of those plans are encouraged to check. Those who are uninsured can seek hospice care at low or no cost through a variety of nonprofit programs and funds, and the California Department of Public Health offers a database of hospice facilities. 

By Sunday, the hospital had arranged for hospice at home for grandma. While I was at the hospital watching after her, my family back home took charge of re-arranging her bedroom to receive the medical equipment that she would need for comfort care: a medical bed, an oxygen machine, and other medical supplies. 

The next day, grandma was transported via ambulance back home. 

Before leaving the hospital, she was given a sedative called Ativan. Shortly after she was given the dose, grandma fell into a deep sleep. By the time grandma was home, she was no longer responsive and remained asleep. 

Grandma Lupe with her grandchildren celebrating birthdays. Credit: Azucena Rasilla

Nothing can ever prepare you for seeing a loved one enter the dying stages. I first noticed the change in how cold her extremities were getting, and her legs and feet turning darker in color due to poor blood circulation. The worst part for me was something called “death rattle”—a sound that dying people make when they can no longer swallow or cough properly to clear saliva. In writing about this, I hope readers will be better prepared to navigate some of the more challenging aspects that the death of a loved one can present.

Grandma was in hospice for a total of three days. On Wednesday, April 13 at 11 p.m., she took her last breath surrounded by her children and grandchildren. My sister had flown in from the East Coast to spend the last few days with grandma. As a medical professional, she was the first one to pronounce grandma dead. 

After grandma’s passing, there were a number of calls we needed to make. The first call was to the hospice provider, so a nurse could come to the home to legally declare grandma dead. That same nurse called the mortuary we had selected to begin the process of collecting grandma’s remains. She had chosen to be cremated and have her ashes placed in a niche in a sacred place. 

Once the nurse made those calls, we had a few hours to be with grandma and say our goodbyes. In the early hours of that Thursday, April 14, the mortuary came to take the body to the funeral home to await cremation. I needed to have all of grandma’s personal information handy, as well as a copy of her advanced directive. After filling out the paperwork, the mortuary transport technician walked into the room to take grandma’s remains. She was wheeled on a gurney into the mortuary’s van.

The next morning, the funeral director called me to request additional personal information in order to process the death certificate. Where was my grandma born? The names of her parents, her date of birth, her race, address, and so on. Death certificates, which must be signed by a doctor—in grandma’s case, a doctor from hospice—are filed with the Alameda County Public Health Department’s vital registration department. Each copy costs $24, and you’ll need several copies in order to close out accounts and transfer the assets of the deceased. 

According to the county health department, death certificate requests usually take up to two weeks to process once they’ve been ordered by a funeral home and payment has been received. But the process can be expedited if necessary for religious burial rites.

Because of grandma’s Catholic faith, we paid an additional $300 to prioritize her cremation, $525 for the urn to place her ashes, $48 for two certified death certificates, plus the added state fees. Although we paid extra to prioritize her cremation, it still took five days for her body to be cremated. 

Even though we thought we’d prepared ourselves financially by signing a contract early on with a mortuary for funeral and burial services, that wasn’t the case. In all, we had to pay over $5,000 in additional upfront costs—more than $3,000 for the cremation and over $2,000 for the down payment (to continue making payments) on the niche where her ashes were placed.

Despite our best efforts, my family was not prepared for the financial burden brought by my grandma’s passing. While I was able to advocate for my family and help us navigate all the complex and expensive paperwork, we could’ve been better prepared. 

For those looking to avoid the same challenges, the Consumer Guide to Funeral and Cemetery Purchases, published by the California Department of Consumer Affairs’ Cemetary and Funeral Bureau, is a great place to start. So is Oakland author Jessica Mitford’s book, The American Way of Death, an exposé of the U.S. funeral industry and its predatory practices towards grieving families. 

Grandma Lupe’s 90th birthday in 2020. Credit: Azucena Rasilla

Earlier this week, I was watching the Country Music Hall of Fame’s induction ceremony for Wynonna Judd and her late mother, Naomi Judd. During her acceptance speech, Judd said, “It’s a very strange dynamic to be this broken and this blessed.” Like Judd, I feel blessed that my job as a journalist allows me the opportunity to write personal essays like this one in hopes that my words can help others. At the same time, as a grieving granddaughter, this has been one of the hardest stories I’ve ever written. I hope it helps other families have an easier time dealing with the unimaginable pain of losing a loved one, and with navigating what happens next. 

Azucena Rasilla is a bilingual journalist from East Oakland reporting in Spanish and in English, and a longtime reporter on Oakland arts, culture and community. As an independent local journalist, she has reported for KQED Arts, The Bold Italic, Zora and The San Francisco Chronicle. She was a writer and social media editor for the East Bay Express, helping readers navigate Oakland’s rich artistic and creative landscapes through a wide range of innovative digital approaches.