Decision-making, regret, and quality of life in living organ donors: a cross-sectional study

Abstract

The aim of this study is to identify factors influencing living donors’ decision-making, regret, and quality of life. This cross-sectional, descriptive, and correlational study was conducted between June and October 2023 and included 128 living liver or other organ donors who were at least three months post-surgery. Data were collected using a questionnaire, the Decision Regret Scale, and the World Health Organization Quality of Life Scale Short Form. The mean age of the participants was 49.48 ± 11.43, 75% of them decided to donate on their own, the mean score on the Decision Regret Scale was 22.5 ± 16.25, and the mean score for general quality of life perception was 63.59 ± 14.2. It was determined that there was a moderate negative correlation between the mean scores of the Decision Regret Scale and the mean scores of the physical, social, and psychological quality of life subdomains. The findings indicated that psychological quality of life and the length of the donation decision-making period were the primary determinants of regret levels (p < 0.05). The psychological well-being of living organ donors and the duration of the decision-making process can influence post-donation regret, which in turn has a direct impact on donors’ quality of life.

Introduction

Organ transplantation is a life-saving treatment for end-stage organ failure, supported by advancements in surgical methods, technology, and immunosuppressive therapies¹. However, the global shortage of donor organs remains a major challenge¹. While cadaveric donors are the primary source in developed countries, living donors are more common in our country². The decision to become a living donor requires consideration of a complex, interactive array of factors³,the protection of their health a key priority⁴. The desire to save a life, the internalization of this desire as an ethical obligation, and spirituality can shape an individual’s personal attitudes and values, thereby motivating them to engage in organ donation⁵. In the Turkish context, organ donation is influenced by multiple sociocultural and psychological factors, including religious beliefs, mistrust in healthcare institutions, concerns about illegal organ trafficking, fear of postmortem bodily disfigurement, media influence, health-related anxieties, and the requirement for family consent⁶. Family relationships between the donor and recipient often play a significant role in motivating individuals to pursue organ donation. In such cases, prospective living donors may voluntarily choose to donate, even when they are fully aware of the potential risks associated with transplantation⁵. However, despite being voluntary, some living donors experience regret after donation, meaning they may feel that donating was the wrong decision or wish they had not proceeded with the donation^7,8. This regret can stem from physical complications—such as pain, hernia, gastrointestinal issues, and sexual dysfunction⁹- as well as psychosocial difficulties including return to work, income loss, depression, and disrupted social relationships¹⁰.

Determining whether living donors experience regret regarding their donation decision is critically important, as they must live with the long-term consequences of both donation and transplant surgery throughout their lives. Evidence indicates that living donors may experience a range of physical complications in the postoperative period, including hernia, pain, adhesions, nausea, diarrhoea, food intolerance, anxiety, depression, discomfort related to scar tissue, and sexual dysfunction, all of which can negatively affect their quality of life^9–11. In addition, the quality of life of living donors may be negatively affected by various psychosocial challenges, including loss of income, financial burden, and health insurance–related problems¹². Furthermore, psychological problems such as depression, anxiety, and sleep disorders have been reported among living donors^10,13,14. Notably, some of these physical and psychosocial problems have been shown to persist for years following surgery^9,11.

Numerous studies on organ transplantation have been conducted both nationally and internationally. However, the majority of this research predominantly focuses on transplant recipients, emphasizing surgical success, immunosuppressive therapies, and post-transplant outcomes such as mortality, quality of life, and treatment adherence^15,16,17 Research has predominantly focused on recipient outcomes, while studies addressing the physical and psychosocial effects of organ transplantation on living donors remain limited^18,19. Various cross-sectional, prospective cohort, and comparative studies have evaluated the quality of life of living donors in the short and/or long term following donation^20–22. Other studies have evaluated depressive symptoms and the prevalence of clinically diagnosed depression among living donors^22,23. In a limited number of studies examining decisional regret among living organ donors, decision conflict and regret experienced by kidney donors up to 12 months after donation have been investigated¹⁸,while in familial living liver donors, the relationship between post-donation regret and anxiety, as well as the mediating roles of family relationships and sense of adequacy, has been examined²⁴. To our knowledge, no studies have specifically examined decisional regret, quality of life, and decision-making duration together. This gap limits the understanding of how decisional regret may influence long-term donor outcomes and highlights the need for studies examining these relationships. Therefore, this study aims to examine the decision-making processes of living organ donors and to analyze the relationships between decision-making duration, decisional regret following donation, and donors’ health-related quality of life. The findings of this study are expected to contribute to the development of structured pre- and post-donation support programs by helping healthcare professionals identify donors at risk of decisional regret, ultimately improving donor well-being and long-term outcomes.

Methods

Study design and setting

This cross-sectional, descriptive, and correlational study was conducted between June and October 2023 with living kidney and liver donors who attended the Nephrology, Urology, and Gastroenterology Polyclinics of a university hospital for postoperative follow-up.

Sample size and sampling

The G*Power (Version 3.1.9.6) program was used to determine the sample size. Based on a multiple linear regression analysis, the sample size was calculated as 128, with a two-tailed hypothesis, effect size = 0.50, α = 0.05, and power (1-β) = 0.80. Due to the heterogeneity of measurement instruments and study designs in the existing literature, it was not possible to derive a consistent effect size estimate. Therefore, a medium effect size (f² = 0.15; equivalent to d = 0.50) was assumed based on conventional criteria proposed by Cohen²⁵. Participation in the study was voluntary, and written informed consent was obtained from all participants prior to data collection. The study included individuals who: (a)were 18 years of age or older, (b) Individuals who are living liver or kidney donors, (c)were at least 3 months postoperative. Individuals were excluded if they: (a)did not attendthe medical follow-up, (b) had incomplete data collection forms or data that could not be completed. Specifically, participants were required to be at least 3 months postoperative to ensure that they had sufficient time to recover from surgery and to adapt to the donation process, allowing for a more stable assessment of decisional regret and quality of life.

Measurement and data collection

Data were collected through face-to-face interviews during postoperative follow-ups of living donors after their outpatient examinations were completed. A consecutive sampling method was used, in which all eligible living donors who attended the outpatient clinic during the study period and met the inclusion criteria were invited to participate. This approach was preferred to reduce selection bias and to ensure that the sample was representative of the accessible population. Following informed consent, participants completed the Questionnaire Form, Decision Regret Scale (DRS), and World Health Organization Quality of Life Scale Short Form (WHOQOL-BREF) in a private room without the presence of companions or healthcare staff. The process took approximately 15–20 min.

Sociodemographic and Medical Characteristics: Form A structured form developed by the researchers was used to collect sociodemographic and clinical characteristics of the participants. This form included sociodemographic (age, gender, educational status) and medical characteristics (age, gender, marital status, donated organ, postoperative complications) based on the relevant literature^3,13. As the form did not aim to measure latent constructs, psychometric validation procedures were not required.

Decision Regret Scale (DRS): The scale, developed by Brehaut and colleagues, evaluates individuals’ regret regarding health-related decisions. The Turkish validity and reliability study of the scale was conducted by Telata et al.²⁶ As the score obtained from the scale increases, the level of regret increases. In the validity and reliability study of the scale, Cronbach’s alpha coefficient was found to be 0.868. In this study, the Cronbach’s alpha reliability coefficient was found to be 0.91.

World Health Organization Quality of Life Scale Short Form (WHOQOL-BREF(TR): The scale is a widely used and validated instrument developed by the World Health Organization to assess individuals’ quality of life across different cultures. The scale consists of 26 items, including two general items on overall quality of life and general health, and four domains: physical, psychological, social, and environmental. Higher scores indicate better quality of life. The Turkish version of the scale was validated by Eser et al.²⁷ and has demonstrated acceptable reliability. In this study, the Cronbach’s alpha coefficients for the physical, psychological, social, and environmental domains were 0.84, 0.82, 0.61, and 0.82, respectively.

Data analysis

Data were analyzed using IBM SPSS Statistics for Windows, Version 22.0. The normality of the data was evaluated using skewness and kurtosis statistics. Values between − 1.5 and + 1.5 were accepted as indicating normal distribution²⁸. Based on these criteria, appropriate parametric or non-parametric statistical tests were applied. Descriptive statistics (number, percentage distribution, mean, standard deviation, and minimum and maximum values) were used in the data evaluation. Independent sample t-tests and one-way analysis of variance were used to compare the WHOQOL-BREF subdimension and DRS score means for normally distributed variables, while the Mann-Whitney U test was used for the comparison of variables that did not show a normal distribution. For categorical variables, the Kruskal-Wallis test was used to compare the mean scores of the DRS, and the post hoc Bonferroni test was used to identify the group causing the difference when there were three or more groups. The Pearson correlation test was used to determine the relationship between the mean WHOQOL-BREF sub-dimension scores and the mean score of the DRS, and multiple regression analysis was used to estimate the relationship between the mean score of the DRS and the related outcomes. Variables included in the multiple regression analysis were selected based on the results of univariate analyses. Specifically, variables that showed a statistically significant association (p < 0.05) with the dependent variable were entered into the regression model.

Ethics approval

This study involving human participants was approved by the Ankara University Ethics Committee (Date: 29.05.2023; Number: 64). Institutional permission was also obtained from the relevant healthcare institution where the study was conducted. Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were informed about the purpose of the study, and their voluntary participation was ensured. The study was conducted in accordance with the principles of the Declaration of Helsinki. In this study, no intervention was performed; therefore, the role of the ethics committee was limited to ethical approval only.

Results

The study was conducted with 128 participants. The mean age of the participants was 49.48 ± 11.43 years; 56.25% were female (Table 1).

Table 1.

Distribution of participants according to sociodemographic and medical characteristics.

Characteristics	n(%)
Age (X±SD)	49.48±11.43
Age
18-39	29(22.66)
40-59	66(51.56)
>60	33(25.78)
Gender
Female	72(56.25)
Male	56(43.75)
Marital status
Married	95(74.22)
Single	33(25.78)
Education status
Primary education	76(59.38)
High School	25(19.53)
University	25(19.53)
Postgraduate	2(1.56)
Employment status
Working	63(49.22)
Not working	65(50.78)
Income level
Low	44(34.38)
Moderate	60(46.88)
High	24(18.75)
Health problem before donation
Yes	24(18.75)
No	104(81.25)
Surgery experience before transplantation
Yes	48(37.50)
No	80(62.50)
Recipient
Relative	123(96.09)
Non-relative	5(3.91)
Relative who donated organs
Child	50(40.65)
Sibling	33(26.83)
Spouse	20(16.26)
Mother	5(4.07)
Nephew	5(4.07)
Cousin	4(3.25)
Father	3(2.44)
Aunt, uncle	1(0.81)
Mother-in-law-father-in-law	2 (1.62)
Non-relative Recipient
Friend	3(60.00)
Spouse’s nephew	1(20.00)
Spouse’s sibling	1(20.00)
Non-relative Recipient
Friend	3(60.00)
Spouse’s nephew	1(20.00)
Spouse’s sibling	1(20.00)
Donated organ
Liver	22(17.19)
Kidney	106(82.81)
Time since transplant surgery
3 months-1year	30(23.44)
1-5years	39(30.47)
>5 years	59(46.09)

The characteristics of the participants regarding the pre-transplant surgery, postoperative period, and the factors affecting the decision to donate organs are given in Table 2. 72.60% of the participants were happy with their decision. 43.75% of the participants decided to donate within 1–3 months, 75.00% decided to donate organs on their own, and 74.21% decided to donate because their health status was suitable for transplantation.

Table 2.

Participants characteristics related to before and after surgery period and the factors affecting the decision to donate organs (n=128) (continued).

Characteristics	n(%)
Recipient’s attitude toward the donor after transplantation
Perceived gratitude	101 (50.70)
Increased attention	75 (37.60)
No change (child recipient)	15 (7.50)
No change	3 (1.50)
Lack of concern	2 (1.00)
The recipient’s current health
Good	111 (86.72)
Bad/ died	17 (13.28)
Decision-making influence
Self-decision	96 (75.00)
Influenced by others*	32 (25.00)
Persons influencing the decision
Recipient	35 (27.34)
Family	50 (39.06)
Physicians	44 (34.37)
Nurses	1 (0.78)
Relatives	25 (19.53)
Transplant coordinator	8 (6.25)
Duration of decision to donate
0-<1 month	33 (25.78)
1-<3 months	56 (43.75)
3-12 months	39 (30.47)
Factors influencing the decision to donate organs
Suitable health status for transplantation	95 (74.21)
Fear of losing a close relative	76 (59.37)
Sense of responsibility toward the recipient	70 (54.68)
Recipient’s poor psychological condition	59 (46.09)
Recipient expectations	40 (31.25)
Avoidance of negative social perception	26 (20.31)
Religious beliefs	22 (17.18)
Desire to prove oneself	20 (15.62)
Desire to be helpful	15 (11.71)
Financial burden of treatment on the family	11 (8.59)
Expectation of improved family relationships	9 (7.03)
Inability to resist family pressure	3 (2.34)
Desire to relieve pressure from relatives	3 (2.34)
Desire to be a “family hero”	2 (1.56)
Preoperative feelings and thoughts
Satisfaction with decision	93 (72.60)
Fear	56 (43.75)
Anxiety	47 (36.71)
Concern about returning to normal life	39 (30.46)
Sense of peace	22 (17.18)
Desire to withdraw	16 (12.50)
Anger toward family/relative	8 (6.25)
Feeling of pressure	7 (5.46)
Regret	5 (3.90)
Feeling of being sacrificed	2 (1.56)

The comparison of the participants’ mean scores on the WHOQOL-BREF General Quality of Life Perception and the mean scores of the sub-domains according to some characteristics is given in Table 3. The mean score of the participants in the General Perception of Quality of Life is 63.59 ± 14.20. The difference between the mean scores of the Environment Domain according to the income levels of the participants is statistically significant (p < 0.05). The mean physical subdomain scores of the working participants and the participants who had not been operated on before are significantly higher than those of the other participants (p < 0.05). The mean social sub-domain scores of married participants are significantly higher than those of single participants (p < 0.05). The psychological subdomain mean scores of male participants, married participants, employed participants, participants with high income level, and participants with good recipient status are significantly higher than those of the other participants (p < 0.05).

Table 3.

The mean WHOQOL-BREF sub-domain scores of the participants and the comparison of the mean WHOQOL-BREF sub-domain scores according to some characteristics of participants.

Characteristics			n	±SS
WHOQOL-BREF-General Quality of Life Total Score			128	63.59±14.20
Özellik	n	WHOQOL- Environment Sub-domain	WHOQOL- Physical Sub-domain	WHOQOL- Social Relationship Sub-domain	WHOQOL- Psychological Sub-domain
		±SS	±SS	±SS	±SS
Total	128	70.20±13.65	74.38±11.61	60.28±16.04	63.28±11.59
Gender
Female	72	60.79±10.74	73.51±11.56	58.77±17.18	60.97±10.39
Male	56	59.14±13.56	75.39±11.96	61.48±14.38	66.59±12.05
t/p		0.77/0.44	-0.90/0.37	-0.95/0.34	-2.83/0.01
Marital status
Married	95	59.69±12.59	74.87±11.48	61.75±15.72	64.74±11.63
Single	33	61.15±10.37	72.77±12.45	54.81±15.94	59.67±10.14
t/p		-0.60/0.55	0.89/0.38	2.18/0.03	2.23/0.03
Employment status
Working	63	60.41±12.39	76.88±10.51	60.06±15.88	65.49±11.49
Not working	65	59.74±11.77	71.86±12.38	59.86±16.25	61.43±11.13
t/p		0.32/0.75	2.47/0.01	0.07/0.94	2.03/0.04
Surgery experience before transplantation
Yes	48	61.38±11.17	71.68±12.82	62.33±14.92	64.17±11.83
No	80	59.29±12.53	75.93±10.79	58.53±16.55	62.99±11.26
t/p		0.95/0.34	-2.01/0.04	1.30/0.19	0.56/0.57
Age Group
18-391	29	59.79±12.06	81.07±8.85	61.00±16.82	64.97±12.18
40-592	66	61.39±13.43	76.28±10.22	59.86±15.75	64.70±11.07
>603	33	57.67±8.45	64.52±10.81	59.24±16.26	59.55±10.95
F/p		1.07/0.35	23.33/0.01 (1>2,3)	0.09/0.91	2.63/0.08
Income level
Low1	44	51.73±10.34	74.80±11.61	57.64±16.21	60.39±11.86
Moderate 2	60	61.67±8.96	74.19±10.92	59.19±16.10	63.83±10.49
High3	24	71.38±11.01	73.83±14.17	66.13±14.42	68.00±11.75
F/p		32.42/0.01 (1<2,3)	0.06/0.94	2.36/0.10	3.65/0.03 (3>1,2)
The recipient’s current state of health
Good	112	70.53±14.14	75.03±11.52	60.86±16.20	64.73±11.52
Bad/Died	16	67.85±9.58	69.86±11.66	56.25±14.75	53.12±5.37
F/p		3.79/0.46	0.125/0.96	1.368/0.28	13.82/0.00
Time since transplant surgery
3months-<1year1	30	60.47±14.29	71.77±11.70	62.60±14.46	63.80±11.15
1-5years2	39	59.74±11.56	79.71±9.15	61.97±16.16	64.26±11.44
>5years3	59	60.08±11.29	72.08±12.24	57.29±16.49	62.69±11.74
F/p		0.03/0.97	6.40/0.00 2>1,3	1.55/0.22	0.24/0.79

Significant values are given in bold.

The comparison of the DRS mean scores of the participants according to some characteristics of the participants is given in Table 4. The mean score of the participants was 22.5 ± 16.25. Single participants, participants whose organ recipient’s current condition was bad/dead, and participants who decided to donate under the influence of others had significantly higher scores (p < 0.05). A statistically significant difference was also found in participants’ mean scores based on the time taken to decide on donation (p < 0.05).

Table 4.

Comparison of the mean scores of Decision Regret Scale (DRS) of the participants according to some characteristics of the participants

Characteristics	n	DRS	t	p
		±SS
DRS Total Score	128	22.5±16.25
Marital status
Married	95	19.89±15.84	-3.19±,	0.01
Single	33	30.00±15.26
Decision-making influence
Self-decision	96	20.00±14.27	-3.12±	0.01
Influenced by others	32	30.00±19.51
Duration of decision to donate
0-1 month1	33	11.52±11.69
1-3 months2	56	23.57±13.84	14.71‡	0.01 1<2,3
3-12 months3	39	30.26±17.95
The recipient’s current health
Good	111	20.72±16.16	3.658‡‡	0.00
Bad/Dead	17	34.11±11.62
Time since transplant surgery
3 months-1year	30	21.83±16.37
1-5years	39	22.56±14.27	0.035‡	0.96
>5 years	59	22.79±17.62

^±Independent sample t test, ^‡One-way analysis of variance, ^‡‡Mann Whitney-U test. Significant values are given in bold.

The relationship between the DRS scores and WHOQOL-BREF sub-domain scores is presented in Table 5. There is a moderate negative correlation between the mean scores of the DRS and the mean scores of the physical (r:−0.32, p = 0.01), social (r:−0.47; p = 0.01), and psychological (r:−0.58; p = 0.01) subdomains.

Table 5.

The Correlation between decision regret scale scores and WHOQOL-BREF subs-domain scores.

WHOQOL-BREF sub-domain	Decision Regret Scale mean score
	r	p
WHOQOL-BREF environment	−0.16	0.07
WHOQOL-BREF physical	−0.32	0.01
WHOQOL-BREF social relationship	−0.47	0.01
WHOQOL-BREF psychological	−0.58	0.01

Significant values are given in bold.

A multiple linear regression analysis was performed including the variables that were found to be significantly associated with DRS scores, namely marital status, time to decision-making for donation, current status of the recipient, and the WHOQOL physical, social relationships, and psychological subscale means (Table 6). The model developed to predict decision regret scores was constructed in three steps. In Model 1, the WHOQOL-BREF psychological subdomain score was a significant predictor of DRS scores (B = − 0.82, β=−0.58, t = − 7.96, p = 0.01), explaining 33% of the variance (R²=0.33, F = 63.38, p = 0.01). In Model 2, the inclusion of the time to donation decision (categorized as 3–12 months, reference: 0–1 month) significantly improved the model (R²=0.37, Adjusted R²=0.36, F = 36.11, p = 0.01). In this model, both the WHOQOL-BREF psychological subdomain score (B = − 0.76, β=−0.53, t = − 7.24, p = 0.01) and decision-making duration (B = 6.45, β = 0.18, t = 2.49, p = 0.01) were significant predictors. In the final model (Model 3), which demonstrated the highest explanatory power (R²=0.40, Adjusted R²=0.39, F = 27.61, p = 0.01), the WHOQOL-BREF psychological subdomain score remained a significant negative predictor of DRS scores (B = − 0.69, β=−0.49, t = − 6.59, p = 0.01). Additionally, decision-making duration remained a significant positive predictor; participants with a decision-making period of 3–12 months had higher DRS scores compared to those with a decision period of 0–1 month (B = 11.67, β = 0.33, t = 3.65, p = 0.01), and those with a duration of 1–3 months also showed higher scores (B = 7.65, β = 0.23, t = 2.66, p = 0.01). Variance inflation factor (VIF) values ranged between 1.00 and 1.71, indicating no evidence of multicollinearity.

Table 6.

Multiple regression analysis of factors affecting the mean score of the decision regression scale

Dependent variable: mean score of the decision regression scale									Overall model significance	R2	Adjusted R2
Model	Variables	B	Standard deviation	Beta	t	p	VIF	F	p
1	Constant	74.61	6.65		11.22	0.01		63.38	0.01	0.33	0.33
	WHOQOL-BREF Psychological	-0.82	0.10	-0.58	-7.96	0.01	1.00
2	Constant	68.49	6.96		9.84	0.01		36.11	0.01	0.37	0.36
	WHOQOL-BREF Psychological Sub-domain	-0.76	0.10	-0.53	-7.24	0.01	1.07
	The donation decision period is categorically 3-12 months (Reference 0-1 month)	6.45	2.59	0.18	2.49	0.01	1.07
3	Constant	59.43	7.60		7.82	0.01		27.61	0.01	0.40	0.39
	WHOQOL-BREF Psychological Sub-domain	-0.69	0.10	-0.49	-6.59	0.01	1.13
	Duration of decision to donate is categorically 3-12 months (Reference 0-1 month)	11.67	3.20	0.33	3.65	0.01	1.71
	Duration of decision to donate is categorical = 1-3 months (Reference 0-1 month)	7.65	2.87	0.23	2.66	0.01	1.60

Significant values are given in bold.

Discussion

The decision of living donors to donate is influenced by environmental, emotional²⁹,and health-related factors³⁰. In this study, most donors were motivated by their good health status. Consistent with the literature, donors perceived adequate health as the primary prerequisite for donation, highlighting the central role of physical well-being in decision-making.

Organ donation surgery in healthy individuals may affect physical health outcomes³¹. In this study, participants aged 18–39 years, who were employed, had no prior surgery, and were 1–5 years post-transplant demonstrated better physical health and overall quality of life. While some studies report similarly high physical quality-of-life levels³²,others have found lower physical subdomain scores³³. Evidence on age-related effects remains inconsistent: some studies report no association³⁴, whereas others indicate lower physical scores among younger donors³⁵and a weak positive correlation with increasing age¹⁹. Findings on time since surgery are also mixed, with some studies reporting declines over time³⁶and others indicating recovery after an initial postoperative decrease⁹. Consistent with these findings, Sarıgöl Ordin et al.¹⁹ reported higher physical scores among younger, employed donors and those 1–5 years post-surgery. These findings may be explained by better baseline health in younger individuals, higher physical scores during the mid-term postoperative period, early postoperative symptom burden, and gradual recovery over time. These findings underscore the need for structured follow-up care and targeted rehabilitation strategies to support physical recovery.

In living donor transplantation, donors’ psychological well-being may be adversely affected¹⁰. In this study, psychological quality-of-life scores were at a moderate level and were lower among female, single, low-income, unemployed participants and those whose recipients had poor health status or had died. The literature reports heterogeneous findings: While some studies have reported that donors’ psychological quality-of-life scores following donation are lower but still higher than those of the general population³⁷, others have documented declines in psychological well-being during the early post-transplant period³⁸,with symptoms such as anxiety and depression³⁹. Previous research has shown that living alone, being single¹⁴, and recipient death⁴⁰negatively affect donors’ psychological well-being after transplantation, and that female donors are at greater risk of post-transplant depression¹⁴. Recipient poor health status has also been identified as a significant factor reducing donors’ quality of life⁴⁰. One study found that psychological difficulties increased markedly when the recipient died¹³. Another reported higher depression scores in women than in men¹⁹. Gender has also been identified as an important determinant of quality of life, as domestic responsibilities and traditional gender-role expectations may disproportionately reduce women’s quality of life⁴¹. The consistency of the present findings with the literature may be explained by the protective role of being married or partnered, which provides social support, economic security, and reduced loneliness⁴¹. Additionally, income level may influence quality of life through its effects on physical, emotional, and social well-being, as well as occupational and social satisfaction⁴¹. These findings underscore the need for targeted psychosocial interventions and structured counseling programs, particularly for vulnerable donor groups, to support psychological well-being and optimize long-term outcomes following donation.

Organ donation from living donors is widely regarded as an altruistic act⁴². In this study, donors reported low levels of regret. This may be explained by strong social support, autonomous decision-making, shorter decision-making periods (0–1 month), and favorable recipient outcomes. Consistent with this finding, previous studies have reported regret rates ranging from 1% to 14%^7,8.The literature suggests that post-donation regret is a multifactorial phenomenon influenced by psychological, social, and clinical factors⁴³. In line with prior research, lower regret was observed among donors who were married, made independent decisions, and reported good recipient health status, whereas regret tends to increase in cases of unfavorable outcomes, particularly recipient death¹³. However, some studies indicate that donors may not regret their decision even in such cases⁴⁴. The low regret observed in this study may also be related to voluntary decision-making, satisfaction with the decision, donation to close relatives—particularly children—and positive perceptions of recipient health. Additionally, rapid decision-making (0–1 month) in response to perceived life-threatening conditions may reduce ambivalence and, consequently, regret. In this context, structured psychosocial support and counseling during the decision-making process may play a critical role in reducing uncertainty and emotional distress, thereby contributing to lower levels of post-donation regret. Providing adequate information, emotional support, and professional guidance may help donors make more informed and autonomous decisions, ultimately improving long-term psychological outcomes.

Post-transplant quality of life in living donors has been reported to be associated with regret regarding the donation decision^7,8. In this study, a moderate negative correlation was found between physical, social, and psychological quality-of-life domains and regret, indicating that lower quality of life was associated with higher regret. Psychological well-being and the duration of the decision-making process were identified as key factors influencing regret. The literature presents inconsistent findings: some studies report lower overall quality of life among donors with regret⁴⁵,while others indicate higher physical quality-of-life scores in those with lower regret⁴⁶. Conversely, some studies have found no significant association between regret and quality of life^7,8. These inconsistencies may reflect the multifactorial nature of regret in living donation. Lower quality of life among donors experiencing regret may be related to the perceived sacrifice of a healthy organ and unfavorable transplantation outcomes, while variations across studies may be explained by differences in sample characteristics, measurement tools, the subjective nature of quality-of-life assessment, donor–recipient relationships, and procedural factors. These findings highlight that optimizing donors’ quality of life through early psychosocial support and structured counseling may play a key role in preventing post-donation regret and improving long-term donor outcomes.

Strengths and limitations of this study

Strengths of this study include the use of standardized and validated instruments to assess decision regret and quality of life, which enhances the reliability and comparability of the findings. However, several limitations should be acknowledged.

First, the study was conducted in a single center with a relatively small sample size, which may limit the external validity and generalizability of the findings to broader and more diverse donor populations. Furthermore, participants were recruited using a consecutive sampling approach among living donors attending outpatient follow-up visits. This may have resulted in the underrepresentation of individuals who did not attend follow-up appointments or who were less engaged with healthcare services, thereby introducing a potential risk of selection bias. Therefore, the findings should be interpreted with caution when generalizing to all living donor populations.

Second, the cross-sectional design of the study limits the ability to draw causal inferences between decision-making processes, regret, and quality of life. In addition, participants were assessed at varying postoperative periods (ranging from 3 months to more than 5 years), which may have introduced recall bias and temporal variability affecting psychological responses and quality-of-life outcomes.

Third, data were collected using self-report measures, which may be subject to response and social desirability bias. Although validated instruments were used, participants’ responses may have been influenced by subjective perceptions and reporting tendencies.

Fourth, although key psychosocial variables were examined, the study did not comprehensively assess all potential psychological (e.g., detailed measures of depression, anxiety) and social influences (e.g., family pressure, cultural expectations, socioeconomic context) that may affect decision-making, regret, and quality of life.

Fifth, the inclusion of both kidney and liver donors may have introduced heterogeneity, as these groups can differ in terms of surgical risk, recovery trajectory, and long-term outcomes.

Sixth, although the study included both kidney and liver donors, subgroup analyses were not performed due to the unequal distribution between groups (kidney donors n = 106; liver donors n = 22), which may have limited the ability to detect subgroup-specific differences and adequately control for potential confounding effects. Therefore, the findings should be interpreted with caution and confirmed through larger, multicenter studies incorporating more comprehensive psychosocial assessments.

Conclusion

The psychological well-being of living organ donors and the duration of their decision-making process play a critical role in shaping post-donation regret, which is closely associated with quality of life. These findings highlight the importance of systematically assessing donors’ psychological status and decision-making processes both before and after donation. In this context, structured, long-term postoperative follow-up programs that include routine psychosocial screening, counseling, and targeted support interventions should be integrated into clinical practice. Such approaches may help identify donors at risk of decisional regret at an early stage and contribute to improving their overall well-being and long-term outcomes.

Author contributions

Conceptualisation: YK and HOC; methodology: YK and HOC; formal analysis: YK; investigation: HOC; validation: YK and HOC; data curation: YK; writing-original draft: YK and HOC; writing-review & editing: YK and HOC; visualisation: HOC; supervision: YK and HOC.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.