A Tactically Interesting Alternative to Death Saves
I find the standard rules for characters Dropping to 0 Hit Points rather unsatisying. The following variant rules provide a richer, more tactical combat experience, while also finding a use for an underutilised resource: hit dice.
This system has additional effects on gameplay, which you should keep in mind when incorporating them into your games:
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Encounter Balance. This system effectively extends a creature's HP. To aid in encounter balance, I recommend you apply it to both PCs and Monsters (which is why the term 'creature' is used throughout). If you don't, combat becomes far too easy.
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More Deadly. This system has the potential to be more deadly for PCs because if they don't fall unconscious at 0 HP, there's no reason for a monster to stop attacking them. That said, there is a significant buffer before outright death, so they have time to break off and regroup. Instant death is unlikely. In addition, all encounters become a little more difficult because monsters don't die when reaching 0 HP. Therefore, you should consider each encounter's difficulty as one level higher, e.g. Easy encounters are Medium, Medium encounters are Hard, etc.
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Longer Combat. When both PCs and Monsters live longer in combat, combat takes more rounds to resolve. This could be a pro or con, depending on your table's tastes. I quite like it.
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Resource Depletion. Finally, when combat goes on longer, PCs inevitably end up burning through more limited-use resources, which changes the number of encounters the party can handle in the 'adventuring day'.
Now that all that needs saying has been said, on to the rules!
Desperation
Condition
When a creature's hit points are reduced to 0 or fewer, it is in Desperation. It can continue to fight but walks a tight line between unconsciousness and recovery. Each hit endured in Desperation inches the creature closer to death.†
Desperation Saving Throws
At the start of its turn, a creature in Desperation must make a single unmodified saving throw, called a desperation saving throw.
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On a roll of 10 or higher, the creature succeeds and regains hit points equal to double its Constitution modifier. A roll of 20 is a critical success, allowing the creature to spend one Hit Die: it rolls this die and regains additional hit points equal to double the number rolled. If the hit point gain from a successful desperation saving throw raises the creature's hit points above 0, its hit point total after healing is halved (rounded up). If the creature's Constitution modifier is 0 or negative and it did not roll a 20, it regains 1 hit point.
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On a roll of 9 or lower, the saving throw counts as a failure. A roll of 1 counts as two failures. The negative effects of each failed save accumulate, as shown in the Failed Desperation Saving Throw table:
Failed Desperation Saving Throw Failures Effect One The creature loses its bonus action, its speed is halved, and it has disadvantage on ability checks. Two The creature has disadvantage on all attack rolls and all saving throws against spells, abilities, magical effects, and conditions. It also receives a -2 penalty to AC. Three The creature falls unconscious. Four or more The creature starts bleeding out. It no longer makes desperation saving throws, but rather loses hit points equal to half its Hit Die value at the start of each of its turns.
Death
If a creature's hit points fall to or below the negative of their hit point maximum (e.g., -30 hit points for a creature with a 30 hit point maximum), they die, regardless of how many desperation saving throws they've failed.
Recovering From Desperation
When a creature's hit points are raised above 0 through healing or other means, it is no longer in Desperation, ending all effects it suffered from failed desperation saving throws. However, if a creature was unconscious before its hit points were raised above 0, it remains unconscious for 1d4 hours, unless it was healed by magical means.
Regroup. While in Desperation and if not within reach of a hostile creature, a creature can use their action to spend one Hit Die. They roll this die and add their Constitution modifier, regaining hit points equal to double the total. If the hit point gain from taking this action raises the creature's hit points above 0, its hit point total after healing is halved (rounded up).
Taking Damage in Desperation
Whenever a creature in Desperation suffers damage, it must make a Constitution saving throw. The DC is either 10 or half the damage taken, whichever is higher. On a failure, the creature suffers a failed Desperation saving throw.
When a creature in Desperation is damaged by a melee attack, the attacker can attempt to render it unconscious. In such instances, the creature makes the Constitution saving throw with disadvantage but the creature only takes half the damage of the attack on a success. On a failure, the creature is rendered unconscious but it does not take any damage from the attack nor fail a desperation saving throw. However, the creature remains in Desperation and continues making desperation saving throws at the start of its turn.
Healing in Desperation
For creatures in Desperation, the following modifications to healing mechanics apply:
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Healing Doubles. Any healing a creature receives while in Desperation is doubled, regardless of its source. If this healing raises the creature's hit points above 0, its hit point total after healing is halved (rounded up).
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Magical Healing. Healing via levelled spells or magical items cannot alter a creature's number of failed desperation saving throws nor prevent it from bleeding out in any way other than by altering its hit point total. In addition, magical healing does not restore hit point loss from bleeding out over and beyond the hit point gain the spell or item provides.
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Stabilization. Successful attempts to stabilize a creature in Desperation (such as using the Spare the Dying cantrip or a successful DC 10 Medicine check) provide the creature with hit points equal to double the stabilizer's primary spellcasting or ability modifier. A creature's hit points cannot exceed 1 through stabilization. Additionally, unless the creature takes damage subsequent to being stabilized, stabilization stops the creature from needing to make a desperation saving throw at the start of its next turn. Stabilization also stops a creature that has four or more failed desperation saves from bleeding out for one minute, but thereafter the creature continues to bleed out until they are no longer in Desperation.
†The effects of Desperation are designed to end once a creature is no longer in Desperation. If you want a slightly grittier variant that imposes additional long-term effects, you can alter the first sentence to:
When a creature's hit points are reduced to 0 or fewer, it is in Desperation and gains a level of Exhaustion.
This variant works best with my linear and gradually scaling Exhaustion variant, as RAW Exhaustion would quickly become too punitive.
You can download a nicely formatted PDF version of both Desperation and Exhaustion from the Homebrew page.
A special note of thanks to u/Lord-of-the-Morning for their contributions to this homebrew. Their extensive knowledge of the 5e system proved invaluable in thinking through the nuances and ramifications of the mechanics.
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