It's a truism that politicians hate to lose power.

But the Fulton and DeKalb County commissions may vote this week or next to give up much of their control over Grady Memorial Hospital.

For decades, Fulton and DeKalb's elected commissioners have appointed all 10 members of the Grady hospital board of trustees.

But the county commissioners' power would be diminished should Grady shift control over policies and budget from the Grady board to a proposed nonprofit.

Ironically, Fulton and DeKalb must give final consent for the change to occur. By law, the two counties must sign off on the lease agreement between the nonprofit and the existing Grady board, which will remain, but with diminished powers.

Several Fulton and DeKalb commissioners say they believe their boards will approve the measure, though last minute negotiations continue.

"I'm very confident that we will vote to support it," said Fulton commission chairman John Eaves.

Fulton is expected to vote on the measure Wednesday and DeKalb on Feb. 26.

DeKalb commissioner Burrell Ellis added, "I just don't see anything there that is a deal-breaker."

Still, several commissioners in both counties say they remain undecided.

The pressure to make the power shift has been building for months, primarily from Republican state lawmakers and Atlanta business leaders who, in exchange, promise millions of dollars of new funding for Grady.

But some county commissioners are not happy about losing a degree of control over the hospital. They say their concerns aren't about political clout, but about protecting public accountability and oversight of Grady's spending.

For the two counties, having final consent represents a moment of power over a wide-ranging, months-long process to save Atlanta's massive charity care hospital. Grady is so in deeply debt that officials say it nearly closed its doors last year. At the same time, some see the moment as the counties' last gasp of significant control over Grady.

The two counties power lies in their authority to appoint the Grady board, with Fulton naming seven members and DeKalb three. The two counties provide about $100 million a year toward Grady's budget, about 14 percent, and some county commissioners don't relish the notion they'll be asked continue to send tax dollars to Grady with less control.

Last-minute negotiations between the counties and the Grady board focus on the counties' desire to retain watchdog authority over Grady's purse strings, a concern driven by some commissioners' belief that Grady management has failed to control spending.

"The truth is they ran it into the ground," said Jeff Rader, a DeKalb commissioner.

Several DeKalb commissioners said they want assurances that at least two of the nonprofit board members will live in DeKalb. They also want approval of the $2.5 million in rent that the nonprofit must pay the Grady board. That's a fraction of the hospital's annual budget of $730 million.

Fulton Commissioner Lynne Riley said she wants assurances that Grady will renegotiate its separate operating contract with Fulton to provide greater accountability on hospital spending.

Some commissioners flatly reject the plan to hand power to a nonprofit. Fulton Commissioner Emma Darnell believes the problem with Grady is not the result of management deficiencies, but of increasing cuts in government funding.

"I don't know of any reason for us to turn over millions of dollars to a group of people that nobody voted for," Darnell said.

The new nonprofit board will be appointed by the Atlanta Chamber of Commerce, the Grady board and the governor, lieutenant governor and speaker of the house. The two counties have no direct appointments.

Some critics worry that structure places too much control in the hands of Atlanta business people, with no direct accountability to taxpayers or patients.

"These captains of industry ... have mindsets in which they tell people what to do, and they go and do it," said Sen. Vincent Fort (D-Atlanta). They don't worry about public input, he said. "That's messy ... but it's democracy."

One probable member of the nonprofit board, former Georgia Pacific chief executive Pete Correll, said the shift to the nonprofit is "a step back toward accountability. ... It's going to manage in a fiscally responsible way, to continue the mission of the hospital." Importantly, it will not drive the hospital to close, he said.

Fulton and DeKalb will still appoint the members of the Grady board, which will have oversight of the nonprofit board, especially to guard Grady's historic mission to serve the poor.

Transferring power from the Grady board, and by extension the Fulton and DeKalb commissions, has been a thrust of the Grady restructuring from the start. The original recommendation by the Metro Atlanta Chamber of Commerce last July stressed the need to create an independent nonprofit governing board "to remove politics from the day to day management and operation of the hospital."

Rep. Mike Jacobs said Grady board members have a responsibility to the hospital but are also tied to the Fulton and DeKalb governments.

Fulton commissioner Tom Lowe believes the Grady board is too political. "It leads to hiring people who shouldn't be hired ... and giving contracts to people who you shouldn't give contracts to."

He added, "I never gave up power any more willingly in my life."

Some state legislators say Fulton and DeKalb shouldn't have so much control over Grady. The hospital is important to the region as metro Atlanta's only top-level trauma center and the training center for one in four physicians in Georgia.

"They shouldn't have that much power," said Rep. Earl Ehrhart (R-Powder Springs). Pointing to a legislative proposal to provide Grady about $30 millions more for trauma care, he said, "If they want state money, they need to let go of some of that power."

Staff writer Ty Tagami contributed to this report.