**5. Conclusion**

To date, there are numerous studies among candidates or recipients of a liver transplant and their donors on their adjustment. Evidence suggests that ESLF is associated with adjustment difficulties including experience of psychological problems and poor quality of life among candidates or recipients of a liver transplant. However, findings have been contradictory regarding the extent of these difficulties partly due to different approaches that studies have taken to defining and measuring psychological problems and quality of life. Transplantation is associated with less psychological problems and improvement in quality of life, with more improvements in physical functioning and less improvements in psychosocial areas. However, although it can be argued that quality of life improves after transplantation, the ways in which this improvement continues over time are not clear. Some studies show that quality of life remains similar during follow-up, whereas other studies show subsequent deterioration. In studies which examine quality of life across different time points following transplantation, recipients with high mortality rates need to be accounted for to avoid bias.

There is also some evidence to suggest that contrary to recipients of a transplant, organ donation surgery is associated with deterioration in quality of life, particularly in physical functioning among donors and experience of psychological problems and poor quality of life among donors. However, findings have also been contradictory regarding the extent of these difficulties partly due to different approaches that studies have taken to defining and measuring psychological problems and quality of life.

As mentioned above, contradictory or inconsistent findings may be due to methodological problems. More specifically, studies have mainly used generic measures of quality of life [81, 85, 101]. Such measures may not be specific and sensitive enough to understand adjustmentrelated issues among recipients of a transplant or their donors. Moreover, studies which examined the long-term implications of liver transplantation and donation have assessed recipients and donors at different times after surgery [19, 84].

Evidence also suggests that high levels of psychological problems such as anxiety and depression negatively influence quality of life directly or as a mediator among recipients of a liver transplant and their donors. One explanation for this evidence is that high levels of these problems impair quality of life directly or as a mediator by, for example, maintaining the sick role [60]. Another explanation is that anxiety and depression may reduce compliance with treatment, and this in turn reduces quality of life [61].

Despite numerous studies on the extent of psychological problems and quality of life, attempts to predict these outcomes have fallen short. There is little evidence to conclude from quantitative studies that particular factors predict outcome. Therefore, more research is needed. The construct of beliefs could guide future attempts to explain these outcomes. A review on adjustment in end-stage renal failure (ESRF) [118] shows that although the variance explained in outcomes by beliefs is small, beliefs have been more consistent in predicting these outcomes than other variables such as social support. One exception for these small effects is the beliefs postulated by the self-regulatory model of illness [119, 120] which is developed on the basis of interviews with patients suffering from different types of chronic physical illnesses. This model includes beliefs about identity, cause, consequences, timeline and cure or controllability of a particular chronic physical illness. Future research may examine the ways in which these beliefs predict these outcomes.

An alternative approach to better understand these outcomes is to be guided by qualitative studies. In terms of beliefs, only one qualitative study [113] examined donors' beliefs about ESLF, transplantation and organ donation surgery. More qualitative research is needed, in particular about recipients' beliefs about ESLF and transplantation.

Overall, qualitative findings suggest that candidates or recipients of a liver transplant and their donors experience ESLF and/or transplantation surgery or organ donation surgery and the process of organ donation in ways that are not identified by quantitative research. God's will, blaming oneself, blaming physicians as causes for recipients' ESLFl, doing the right thing, being healed as reasons for being a donor, the views that others are frightened of getting infected by ESLF and insensitive, experience of positive emotions, ways of improving, worsening aspects of character and close relationships are among findings which extend quantitative findings. These findings can be used not only to develop ESLF-specific quality of life or emotional well-being questionnaires but also patient- or donor-derived interventions to improve poor outcomes.
