Objectives: Adult-to-adult living liver donation (LLD) is a controversial procedure due to the risk to the healthy donor. The decision to proceed with LLD is an important, yet under-researched area. This study aims to explore the decision-making process of the donor and recipient independently, and within the donor-recipient dyad. Design: A longitudinal, qualitative analysis of the LLD decision from the perspective of a LLD donor-recipient dyad. Methods: In-depth interviews were conducted with the donor and recipient separately on three occasions: pre LLD, six weeks post and six months post LLD. Transcripts were subject to interpretative phenomenological analysis. Results: During the pre-LLD interviews, a series of intra- and interpersonal negotiations were reported as both the donor and recipient grappled to make a decision about LLD. Following the decision, the focus then centred on the consequences of the decision and making sense of unanticipated outcomes. By six months post LLD, both were able to reflect on adapting to the changes their decision had ultimately caused. Conclusions: This case study offers a unique insight into the risk assessment and decision-making demands of LLD and the results can help support future LLD candidates.