5e has an issue with whack-a-mole game play, where it doesn't even make sense to heal people until they're down, because if you wait until they're down all the overflow damage vanishes, and a first level bonus action healing word is all you need. NPCs can block that, but doing so either requires killing them before they can be healed, or somewhat specialized abilities that prevent healing (typically this means denying vision of the victim, heal suppression, or effects that trigger when they reduce a target to 0 hp).
I don't want to just outright kill off downed PCs, but I do want being reduced to 0 hp being more than a mild inconvenience. Any suggestions that people have found work well?
Some things I've considered (though not implemented in current campaign):
Characters can have negative hit points, which must be healed to raise the character.
Overflow damage reduces max hp.
Downed characters remain incapacitated until the end of their first turn above 0 hp.
but don't really love any of those options.
For comparison:
In AD&D, negative hit points were not a thing; you just died at 0
In 3/3.5e, negative hit points were a thing, but overflow damage had to be healed, and with only 10 of them, higher level enemies would probably just blow through them anyway. Also, swift action heals were only available with metamagic.
4e had some of the same issues as 5e, but healing word or equivalent was generally a pretty limited resource (most parties only had 2 of them available).
I would just make the players aware that in a world where and unconcious party member can be brought back to full fuctionality with a bonus action and a low level spell an intelligent bad guy is going to try and make sure if they go down thay stay down. There is also a possibibity that a low intelligence enemy will try to get a meal before dealing with / running away from the remaining party members.
It is a balancing act, you don't want party deaths when the party didn't do anything wrong, so the bad guys wont always attack a downed party member. If a crit or large damage roll ruduced a PC from over half health to unconcious I would probably leave them to be healed up or maybe givethem a single attack if I knew the healer was next so they could be brought up before making a death save. Knowing that downed party members are still legitimate targets changes the players approach a character one hit from being unconcious is 2 hits from being 2 death saves down so really needs more hit points.
The problem comes in that healing is so inefficient as most levels. A 1st level cure wounds is great for a 1st level character but healing rapidly fails to keep up with damage. Say a level 4 party are fighting a giant scorpian (CR3) The fighter has 40 HP and gets hit by the stinger and fials his con save and takes slightly above aver 35 healing. He now has 5HP left but it is most likely the biggest healing available is a 2nd level cure wounds which will heal an average of 13 (if the casted has a +4 modifier), if the fighter gets stung again he is likely to go down even with the healing and even if he makes the save. This can be dealt with if the DM gives the party a chance to escape, a real party facing low odds of survival woould try to run away but a lot of players don't think of that as an option.
I would just make the players aware that in a world where and unconcious party member can be brought back to full fuctionality with a bonus action and a low level spell an intelligent bad guy is going to try and make sure if they go down thay stay down.
My point is: I don't want to have monsters continually doing finishing blows on downed PCs.
What’s wrong with the negative hit points? You don’t need to limit them to 10 or anything. Give them a number of negative HP/Overflow Damage equal to their normal HP. It doesn’t even have to affect the Death Saving Throws system at all, have the damage be tracked as well as the failed death saves. It just needs to be a pool that needs to be healed through before the PC can yo-yo. I hope that made sense.
the problem comes in that healing is so inefficient as most levels. A 1st level cure wounds is great for a 1st level character but healing rapidly fails to keep up with damage. Say a level 4 party are fighting a giant scorpian (CR3) The fighter has 40 HP and gets hit by the stinger and fials his con save and takes slightly above aver 35 healing. He now has 5HP left but it is most likely the biggest healing available is a 2nd level cure wounds which will heal an average of 13 (if the casted has a +4 modifier), if the fighter gets stung again he is likely to go down even with the healing and even if he makes the save. This can be dealt with if the DM gives the party a chance to escape, a real party facing low odds of survival woould try to run away but a lot of players don't think of that as an option.
It's exactly this. Healing is just not good enough to use in low level combat, except as a way to get people up from zero. You need to rebalance all the healing to make it worthwhile.
You can make combat more brutal, with zero HP more scary, and that's fine, but then you will see a lot more characters die (also fine) and little if any extra healing. It's not worth it. I "heal" more by bringing an enemy down a turn early.
If it's death-at-0, using the current rules, then I can either heal someone in a way that very likely makes no difference (i.e. less than what they need to survive) or I can try to finish off whatever is kill them. The second is probably better.
If Cure Wounds had a bonus, like a mini-bless or imposed disadvantage agains the healed person's next attacker, then it'd still only be worth it with some extra healing on top, I reckon. At least it would be closer to worth it, though, and no extra advantage outside of combat.
You can borrow the path finder 2e wounded rule. Basically every time you go down the number of fails to die decreases, starting at 5 and going down by 1 each time you are knocked down eventually reaching 0 at which point you instantly die the next time you are knocked down. This number is restored by being restored to full hit points and resting.
I used this in a game with a paladin because I was worried about 1 hit point lay on hands heals being too available. It didn't significantly increase the rate of deaths.
I can think of some variations to make it hasher or easier:
Change the length of the rest required which will prioritise healing spells to heal over rests to heal
Make it so rests on reduce a certain number at a time like exhaustion which prioritises avoiding the condition
Reduce or increase the number of saves making it more or less deadly. Some monsters could even have the ability to do this
choose some spells or abilities that heal or don't heal wounds making it a specific skill to spec into
In AD&D, negative hit points were not a thing; you just died at 0
This is not correct.
You could be taken to -10 hp before you died. You would lose 1 hp per round if nobody helped you. If another PC bound your wounds or used magic, you were stabilized. However being at negative hp really messed you up.
This conversation is making me re-think 0 hp and death saves.
Either way, negative hp or death saves I think I'm going to consider levels of exhaustion for every failed death save or at -4 and -8 hp... Something to think about.
Rollback Post to RevisionRollBack
"Sooner or later, your Players are going to smash your railroad into a sandbox."
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"real life is a super high CR."
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"............anybody got any potatoes? We could drop a potato in each hole an' see which ones get viciously mauled by horrible monsters?"
The main consequence of 'whack a mole' I do not like is players will continue to fight with full effectiveness after they are downed.
I have not tried this but an option would be to make someone who has been unconcious muck weaker offensively until they have had a short rest. Something like disadvantage on all attacks and a reduction of 5 to save dc (if they cast spell or for things like stunning strike). Defensively theyare unchanged and they are at full capacity if they want to escape (they can still cast spells like dimension door)
I think that the most effective way I've seen is to give out exhaustion for being revived. It'll really discourage anyone from being dropped to 0hp more than once per long rest, and it'll build up in a realistic way - if you've very nearly died 5 times in one day, then you'll probably need a week of recovery to shake that off.
You could combine it with a house rule for a "Luxurious Rest", which is at least 12 hours and requires warmth and comfort, and takes off 2 levels of exhaustion - IE, finding a tavern and staying there for the night, rather than a bed roll at the side of the road next to a guttering fire and under a blanket which smells of horse and is damp from when you fell in the river yesterday.
This will encourage not dropping to 0hp, and give lingering effects for those who "die" too often. Throw them some energy drinks which remove exhaustion if it becomes too punishing, or a magic bedroll which gives a luxurious rest on every long rest.
If you are reduced to 0 hit points, you lose one slot, and then begin to make death saving throws as per usual.
If you fail a death saving throw, you lose another slot.
If you lose your 4th slot, you die.
Slots can only be recovered by resting. You regain 1 lost slot on a Short Rest, and 3 slots on a Long Rest.
Example gameplay:
Jon the Paladin is hit by the Gnoll, and knocked unconscious. He loses 1 Death Saving Throw Slot (DSTS) and has 3 remaining.
Jon receives a Healing Word from an ally. He gets up and takes his turn.
Jon is hit by another Gnoll, and again knocked unconscious. He loses 1 Death Saving Throw Slot, and now has only 2 remaining.
On his turn, Jon fails a death saving throw. He has 1 slot remaining. He still needs to pass 3 successful death saving throws to stabilise.
Jon receives another Healing Word, recovers on 5 hit points and stands up. He attempts to kill the gnoll, but instead rolls a nat 1 and misses.
The Gnoll hits Jon yet again, sending him to the ground. Jon has 0 Death Saving Throw Slots left to him, and is dead.
This effectively means that even without rolling a death saving throw, getting knocked unconscious 4 times in one adventuring day is certain death, and each time the PC gets knocked unconscious, they will lose automatically lose another. Note that they have 4 slots so that the first time they go down they still have 3 slots (standard 3 death saving throws) but it gets harder each time, and getting KO'd always eats one.
5e has an issue with whack-a-mole game play, where it doesn't even make sense to heal people until they're down, because if you wait until they're down all the overflow damage vanishes, and a first level bonus action healing word is all you need. NPCs can block that, but doing so either requires killing them before they can be healed, or somewhat specialized abilities that prevent healing (typically this means denying vision of the victim, heal suppression, or effects that trigger when they reduce a target to 0 hp).
I don't want to just outright kill off downed PCs, but I do want being reduced to 0 hp being more than a mild inconvenience. Any suggestions that people have found work well?
Some things I've considered (though not implemented in current campaign):
Characters can have negative hit points, which must be healed to raise the character.
Overflow damage reduces max hp.
Downed characters remain incapacitated until the end of their first turn above 0 hp.
but don't really love any of those options.
For comparison:
In AD&D, negative hit points were not a thing; you just died at 0
In 3/3.5e, negative hit points were a thing, but overflow damage had to be healed, and with only 10 of them, higher level enemies would probably just blow through them anyway. Also, swift action heals were only available with metamagic.
4e had some of the same issues as 5e, but healing word or equivalent was generally a pretty limited resource (most parties only had 2 of them available).
I agree that it is mechanically inefficient for someone to toss healing out to a PC that hasn't dropped to 0 hp, and that process may have become the norm because many players find it more fun to play in the most optimal manner possible. Perhaps there is some influence that not doing it this way is considered wrong or un-fun, maybe?
"How do you make dropping to 0 hp more meaningful in your game?" seems to be the gist of the question. Are you and your players looking to add layers of mechanical bits to track during combat encounters? Or are you looking to make healing *during* combat more viable and worth the action economy to keep a PC on their feet?
If you're looking to improve healing during combat, you might consider consumption of healing potions as a BA, inclusion of Healing Surges, or maybe rework the healing spell dice by tier of play (ie. Tier 2 - HW=d6, CW=d10 / Tier 3 - HW=d8, CW=d12...) so that it scales better with the amount of hp that the PCs have. Alternatively, you could slow down the rate of hp gain by the PCs to make the healing spells, as-written, suddenly become more effective.
If you're more fond of adding mechanical bits to track, there is always Injuries, Healing, and Rest Variants in Ch. 9 of the DMG. You might consider adding a level of exhaustion each time the PC hits 0 hp, or not resetting Death Saves until the next long (or maybe short) rest.
While I appreciate the hesitance of outright killing a PC, and the leaning away from performing killing blows on PCs, the methods of making something like healing worth the action economy generally involve the consequences of not using action economy for healing. And that might mean outright killing PCs. After all, a thing is only valuable to someone who needs wants it, and doesn't possess it.
“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.” - Mark Twain - Innocents Abroad
I echo others' suggestion of exhaustion and lingering injuries, though my mindset is based on video games. In Fable each time you die you get a scar which some people may find attractive but most find repulsive, in Dragon Age you have the Injuries and Injury Kit system, in Fallout you have Medicine and Surgery. In Dragon Age, an Injury is a debuff that can only be treated by an Injury Kit. In Fallout, crippled limbs have debuffs that can be healed (if only slightly) by stimpaks but are better restored via a Doctor's Bag. In the case of the latter two games, treatment for crippling injuries is both limited and expensive, whereas standard potions and spells are a dime-a-dozen.
So there are systems out there you can take inspiration of which will discourage your party members falling unconscious. If those were more prominent in the game where I'm playing a Cleric of the Grave Domain, I'd be considerably more careful about waiting to use my domain feature of full healing when bringing back the unconscious.
Rollback Post to RevisionRollBack
Zero is the most important number in D&D: Session Zero sets the boundaries and the tone; Rule Zero dictates the Dungeon Master (DM) is the final arbiter; and Zero D&D is better than Bad D&D.
"Let us speak plainly now, and in earnest, for words mean little without the weight of conviction."
One way i make Dying more meaningful in my campaign is by having Dying creature gains a level of Exhaustion whenever it drop to 0 hit points, thus more often invoking this special condition, which is somewhat underused.
In AD&D, negative hit points were not a thing; you just died at 0
This is not correct.
You could be taken to -10 hp before you died. You would lose 1 hp per round if nobody helped you. If another PC bound your wounds or used magic, you were stabilized. However being at negative hp really messed you up.
This conversation is making me re-think 0 hp and death saves.
Either way, negative hp or death saves I think I'm going to consider levels of exhaustion for every failed death save or at -4 and -8 hp... Something to think about.
Similar to others, but layered on top of each other. I only use negative to determine if a character is killed outright (e.g. you go as far into negative as your hp max).
Once you are down, every failed death save gives one level of exhaustion and you roll for a lingering injury (we use the World of Farland's table that varies lingering injuries by the type of damage you took). Players can still be brought up by healing, but there's a lot more risk involved in picking up lingering injuries that seriously reduces your ability to continue functioning in an adventure.
As a rather more convoluted idea that I haven;t quite fleshed out.....
If you want staying at higher HP to be more relevant how about this, each character's HP total is divided into 6 levels, level 1 =100 to 81% of HP, level 2 =80 to 61%, level 3 = 60 to 41%, level 4 =40 to 21%, level 5 =20 to 1% and level 6 =0% or less HP.
As a character loses HP and moves from one level to next they gain a level of exhaustion to represent accumulation of wounds, combat fatigue etc. as long as you stay in the 81-100% Hp level you are fine and dandy, drop to 61-80% and you have level 1 exhaustion etc.
If you drop to zero HP youi make death saves as usual but I would not have the disadvantage to saving throws due to exhauistion apply to these.
Exhaustion gained from losing HP stacks with gaining exhaustion from other effects. It should be relatively easy to divide a characters HP by 5 to get the HP threshholds for each level.
EDIT considering the death spiral this coudl lead to, maybe divide the HP into 3 levels instead so each level is 33% of Hp and you dont get tot eh half max HP stage of exhaustion....as I said, not completely thought htis through yet.
When any creature is brought to 0 hit points (optionally as low as -3 hit
points if from the same blow which brought the total to 0), it is unconscious.
In each of the next succeeding rounds 1 additional (negative) point
will be lost until -10 is reached and the creature dies. Such loss and death
are caused from bleeding, shock, convulsions, non-respiration, and similar
causes. It ceases immediately on any round a friendly creature administers
aid to the unconscious one. Aid consists of binding wounds, starting
respiration, administering a draught (spirits, healing potion, etc.), or otherwise
doing whatever is necessary to restore life.
Any character brought to 0 (or fewer) hit points and then revived will
remain in a coma far 1-6 turns. Thereafter, he or she must rest for a full
week, minimum. He or she will be incapable of any activity other than that
necessary to move slowly to a place of rest and eat and sleep when there.
The character cannot attack, defend, cast spells, use magic devices, carry
burdens, run, study, research, or do anything else. This is true even if cure
spells and/or healing potions are given to him or her, although if a heal
spell is bestowed the prohibition no longer applies.
If any creature reaches a state of -6 or greater negative paints before
being revived, this could indicate scarring or the loss of some member, if
you so choose. For example, a character struck by a fireball and then
treated when at -9 might have horrible scar tissue on exposed areas of
flesh - hands, arms, neck, face.
AD&D DMG p 82
I didn't see a part where these rules are listed as optional.
I'm beginning to lean towards exhaustion for failed death saves.
I like and dislike the CON loss idea. After going down a bit your max hp goes down which makes it easier for you to be knocked down in the future. But knowing this up front makes the party aware and try to avoid being taken down.
5e has an issue with whack-a-mole game play, where it doesn't even make sense to heal people until they're down, because if you wait until they're down all the overflow damage vanishes, and a first level bonus action healing word is all you need. NPCs can block that, but doing so either requires killing them before they can be healed, or somewhat specialized abilities that prevent healing (typically this means denying vision of the victim, heal suppression, or effects that trigger when they reduce a target to 0 hp).
I don't want to just outright kill off downed PCs, but I do want being reduced to 0 hp being more than a mild inconvenience. Any suggestions that people have found work well?
Some things I've considered (though not implemented in current campaign):
but don't really love any of those options.
For comparison:
I would just make the players aware that in a world where and unconcious party member can be brought back to full fuctionality with a bonus action and a low level spell an intelligent bad guy is going to try and make sure if they go down thay stay down. There is also a possibibity that a low intelligence enemy will try to get a meal before dealing with / running away from the remaining party members.
It is a balancing act, you don't want party deaths when the party didn't do anything wrong, so the bad guys wont always attack a downed party member. If a crit or large damage roll ruduced a PC from over half health to unconcious I would probably leave them to be healed up or maybe givethem a single attack if I knew the healer was next so they could be brought up before making a death save. Knowing that downed party members are still legitimate targets changes the players approach a character one hit from being unconcious is 2 hits from being 2 death saves down so really needs more hit points.
The problem comes in that healing is so inefficient as most levels. A 1st level cure wounds is great for a 1st level character but healing rapidly fails to keep up with damage. Say a level 4 party are fighting a giant scorpian (CR3) The fighter has 40 HP and gets hit by the stinger and fials his con save and takes slightly above aver 35 healing. He now has 5HP left but it is most likely the biggest healing available is a 2nd level cure wounds which will heal an average of 13 (if the casted has a +4 modifier), if the fighter gets stung again he is likely to go down even with the healing and even if he makes the save. This can be dealt with if the DM gives the party a chance to escape, a real party facing low odds of survival woould try to run away but a lot of players don't think of that as an option.
My point is: I don't want to have monsters continually doing finishing blows on downed PCs.
What’s wrong with the negative hit points? You don’t need to limit them to 10 or anything. Give them a number of negative HP/Overflow Damage equal to their normal HP. It doesn’t even have to affect the Death Saving Throws system at all, have the damage be tracked as well as the failed death saves. It just needs to be a pool that needs to be healed through before the PC can yo-yo. I hope that made sense.
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You could give a level of exhaustion if they hit 0. It’s meaningful without being too punishing, and it will add up.
It's exactly this. Healing is just not good enough to use in low level combat, except as a way to get people up from zero. You need to rebalance all the healing to make it worthwhile.
You can make combat more brutal, with zero HP more scary, and that's fine, but then you will see a lot more characters die (also fine) and little if any extra healing. It's not worth it. I "heal" more by bringing an enemy down a turn early.
If it's death-at-0, using the current rules, then I can either heal someone in a way that very likely makes no difference (i.e. less than what they need to survive) or I can try to finish off whatever is kill them. The second is probably better.
If Cure Wounds had a bonus, like a mini-bless or imposed disadvantage agains the healed person's next attacker, then it'd still only be worth it with some extra healing on top, I reckon. At least it would be closer to worth it, though, and no extra advantage outside of combat.
You can borrow the path finder 2e wounded rule.
Basically every time you go down the number of fails to die decreases, starting at 5 and going down by 1 each time you are knocked down eventually reaching 0 at which point you instantly die the next time you are knocked down. This number is restored by being restored to full hit points and resting.
I used this in a game with a paladin because I was worried about 1 hit point lay on hands heals being too available. It didn't significantly increase the rate of deaths.
I can think of some variations to make it hasher or easier:
This is not correct.
You could be taken to -10 hp before you died. You would lose 1 hp per round if nobody helped you. If another PC bound your wounds or used magic, you were stabilized. However being at negative hp really messed you up.
This conversation is making me re-think 0 hp and death saves.
Either way, negative hp or death saves I think I'm going to consider levels of exhaustion for every failed death save or at -4 and -8 hp... Something to think about.
"Sooner or later, your Players are going to smash your railroad into a sandbox."
-Vedexent
"real life is a super high CR."
-OboeLauren
"............anybody got any potatoes? We could drop a potato in each hole an' see which ones get viciously mauled by horrible monsters?"
-Ilyara Thundertale
Lingering Injuries mentioned in the DMG is a good option, see https://www.dndbeyond.com/sources/dmg/dungeon-masters-workshop#Injuries
It encourages players NOT to allow a character to reach 0 hp.
The main consequence of 'whack a mole' I do not like is players will continue to fight with full effectiveness after they are downed.
I have not tried this but an option would be to make someone who has been unconcious muck weaker offensively until they have had a short rest. Something like disadvantage on all attacks and a reduction of 5 to save dc (if they cast spell or for things like stunning strike). Defensively theyare unchanged and they are at full capacity if they want to escape (they can still cast spells like dimension door)
I think that the most effective way I've seen is to give out exhaustion for being revived. It'll really discourage anyone from being dropped to 0hp more than once per long rest, and it'll build up in a realistic way - if you've very nearly died 5 times in one day, then you'll probably need a week of recovery to shake that off.
You could combine it with a house rule for a "Luxurious Rest", which is at least 12 hours and requires warmth and comfort, and takes off 2 levels of exhaustion - IE, finding a tavern and staying there for the night, rather than a bed roll at the side of the road next to a guttering fire and under a blanket which smells of horse and is damp from when you fell in the river yesterday.
This will encourage not dropping to 0hp, and give lingering effects for those who "die" too often. Throw them some energy drinks which remove exhaustion if it becomes too punishing, or a magic bedroll which gives a luxurious rest on every long rest.
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I run this:
Example gameplay:
This effectively means that even without rolling a death saving throw, getting knocked unconscious 4 times in one adventuring day is certain death, and each time the PC gets knocked unconscious, they will lose automatically lose another. Note that they have 4 slots so that the first time they go down they still have 3 slots (standard 3 death saving throws) but it gets harder each time, and getting KO'd always eats one.
For big, dangerous fights, knock out the healer first, then knock out another player.
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HERE.I agree that it is mechanically inefficient for someone to toss healing out to a PC that hasn't dropped to 0 hp, and that process may have become the norm because many players find it more fun to play in the most optimal manner possible. Perhaps there is some influence that not doing it this way is considered wrong or un-fun, maybe?
"How do you make dropping to 0 hp more meaningful in your game?" seems to be the gist of the question. Are you and your players looking to add layers of mechanical bits to track during combat encounters? Or are you looking to make healing *during* combat more viable and worth the action economy to keep a PC on their feet?
If you're looking to improve healing during combat, you might consider consumption of healing potions as a BA, inclusion of Healing Surges, or maybe rework the healing spell dice by tier of play (ie. Tier 2 - HW=d6, CW=d10 / Tier 3 - HW=d8, CW=d12...) so that it scales better with the amount of hp that the PCs have. Alternatively, you could slow down the rate of hp gain by the PCs to make the healing spells, as-written, suddenly become more effective.
If you're more fond of adding mechanical bits to track, there is always Injuries, Healing, and Rest Variants in Ch. 9 of the DMG. You might consider adding a level of exhaustion each time the PC hits 0 hp, or not resetting Death Saves until the next long (or maybe short) rest.
While I appreciate the hesitance of outright killing a PC, and the leaning away from performing killing blows on PCs, the methods of making something like healing worth the action economy generally involve the consequences of not using action economy for healing. And that might mean outright killing PCs. After all, a thing is only valuable to someone who
needswants it, and doesn't possess it.“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.” - Mark Twain - Innocents Abroad
I echo others' suggestion of exhaustion and lingering injuries, though my mindset is based on video games. In Fable each time you die you get a scar which some people may find attractive but most find repulsive, in Dragon Age you have the Injuries and Injury Kit system, in Fallout you have Medicine and Surgery. In Dragon Age, an Injury is a debuff that can only be treated by an Injury Kit. In Fallout, crippled limbs have debuffs that can be healed (if only slightly) by stimpaks but are better restored via a Doctor's Bag. In the case of the latter two games, treatment for crippling injuries is both limited and expensive, whereas standard potions and spells are a dime-a-dozen.
So there are systems out there you can take inspiration of which will discourage your party members falling unconscious. If those were more prominent in the game where I'm playing a Cleric of the Grave Domain, I'd be considerably more careful about waiting to use my domain feature of full healing when bringing back the unconscious.
Zero is the most important number in D&D: Session Zero sets the boundaries and the tone; Rule Zero dictates the Dungeon Master (DM) is the final arbiter; and Zero D&D is better than Bad D&D.
"Let us speak plainly now, and in earnest, for words mean little without the weight of conviction."
- The Assemblage of Houses, World of Warcraft
One way i make Dying more meaningful in my campaign is by having Dying creature gains a level of Exhaustion whenever it drop to 0 hit points, thus more often invoking this special condition, which is somewhat underused.
This is also how I remember us playing.
Similar to others, but layered on top of each other. I only use negative to determine if a character is killed outright (e.g. you go as far into negative as your hp max).
Once you are down, every failed death save gives one level of exhaustion and you roll for a lingering injury (we use the World of Farland's table that varies lingering injuries by the type of damage you took). Players can still be brought up by healing, but there's a lot more risk involved in picking up lingering injuries that seriously reduces your ability to continue functioning in an adventure.
As a rather more convoluted idea that I haven;t quite fleshed out.....
If you want staying at higher HP to be more relevant how about this, each character's HP total is divided into 6 levels, level 1 =100 to 81% of HP, level 2 =80 to 61%, level 3 = 60 to 41%, level 4 =40 to 21%, level 5 =20 to 1% and level 6 =0% or less HP.
As a character loses HP and moves from one level to next they gain a level of exhaustion to represent accumulation of wounds, combat fatigue etc. as long as you stay in the 81-100% Hp level you are fine and dandy, drop to 61-80% and you have level 1 exhaustion etc.
If you drop to zero HP youi make death saves as usual but I would not have the disadvantage to saving throws due to exhauistion apply to these.
Exhaustion gained from losing HP stacks with gaining exhaustion from other effects. It should be relatively easy to divide a characters HP by 5 to get the HP threshholds for each level.
EDIT considering the death spiral this coudl lead to, maybe divide the HP into 3 levels instead so each level is 33% of Hp and you dont get tot eh half max HP stage of exhaustion....as I said, not completely thought htis through yet.
I didn't see a part where these rules are listed as optional.
I'm beginning to lean towards exhaustion for failed death saves.
I like and dislike the CON loss idea. After going down a bit your max hp goes down which makes it easier for you to be knocked down in the future. But knowing this up front makes the party aware and try to avoid being taken down.
"Sooner or later, your Players are going to smash your railroad into a sandbox."
-Vedexent
"real life is a super high CR."
-OboeLauren
"............anybody got any potatoes? We could drop a potato in each hole an' see which ones get viciously mauled by horrible monsters?"
-Ilyara Thundertale