Knocking on Death’s Door: Alternative Rules for Lingering Injuries & Losing Consciousness in D&D 5E

Ever noticed how tough battles in D&D tend to turn into a game of whack-a-mole? One hero reaches 0 HP and falls over. One of their friends runs over and casts cure wounds or force-feeds them a potion and they’re back up again. A round or two later, someone else drops and the cycle repeats.

I think the main reason for this is the sudden transition from up and fighting to comatose and bleeding out on the floor. True, the players can see their HP dropping, so they know they’re getting closer to death, but there’s no mechanic that really drives that home, that says, “Hey, buddy—maybe it’s time to cut your losses and retreat.” Without that nudge, players tend to keep fighting until they drop, and at that point there’s nothing they can do but wait for someone to tag them back in.

To address this issue, I’ve added a house rule to my D&D games. It gets the job done, and my players enjoy it, too. But before I explain how it works, let me give credit where credit’s due. I modeled this idea off of a post by the Angry GM. I tweaked it to suit my taste, but he’s the one who came up with the basic concept.

It involves adding a new condition called “dispirited.” A PC becomes dispirited when they reach 0 HP. When the PC becomes dispirited, they gain 1 level of exhaustion. As soon as they have at least 1 HP, they’re no longer dispirited.

The effects of being dispirited are:

  • You can’t attack or cast spells.
  • If you’re damaged again, you suffer a lingering injury. Also, you must make a Constitution saving throw. If the result is lower than 10 or the amount of damage you just took (whichever is higher), you become unconscious and unstable.

The idea here is to encourage the PC to pull back by cutting off their ability to contribute to the battle while adding the threat of real, long-term consequences. It also has the benefit of giving players something to do when they reach 0 HP and giving the GM a fair mechanic for introducing lingering injuries, which make the battles feel more brutal and realistic.

Speaking of lingering injuries, I find the table in the Dungeon Master’s Guide too complex for my taste. Here’s my own trimmed down version:

Lingering Injury. If you take damage while at 0 HP or if the damage is of an especially serious nature, you gain a lingering injury. The GM can choose something from the table below or have you roll 1d20. Only magical healing of 6th level or higher removes a lingering injury.

  • (1-5) Permanent Scar. A nice conversation starter.
  • (6-8) Impaired Arm. Disadvantage on any action that requires the injured arm, such as attacking, climbing, grappling, or swimming. Heals after a 10-day rest.
  • (9-11) Limp. Total movement speed reduced by 5. Disadvantage on climbing, jumping, etc. Heals after a 10-day rest.
  • (12-13) Internal Wound. You must succeed on a DC 10 Constitution save in order to take any combat action or reaction. Heals after a 10-day rest.
  • (14-15) Festering Wound. Your maximum HP drops by 1 each day. If you reach 0 max HP, you die. Heals after you have been successfully treated five times (DC 15 Medicine check once per day).
  • (16-17) Disfigured. Disadvantage on Persuasion. Advantage on Intimidation.
  • (18) Ruined/Lost Leg. Your total movement speed is halved. Disadvantage on climbing, jumping, etc.
  • (19) Ruined/Lost Arm. You can’t use your left or right hand. Disadvantage on climbing, grappling, swimming, etc.
  • (20) Lost Eye. Disadvantage on Perception. If you have already lost an eye, you become blind.