15 Ways to Make D&D 5e More Deadly

1. Exhaustion (2024 Edition) 

Perhaps my favorite method for introducing the threat of death is exhaustion. The exhaustion system can lead to a character’s death, and for every level of exhaustion they take, the death spiral gets worse. Now, I must say that the 2024 exhaustion rules ARE EVEN BETTER than the 2014 ones. Why? Because they are more brutal, and that’s why we’re here today, isn’t it? Anyway, because each level of exhaustion requires a full long rest to recover, it’s a mechanic that’s tough to shake off. While it doesn’t come up often, you can add extreme conditions like heat and cold to wear down the party and increase those odds.

Furthermore, although there are few RAW monsters in the books that cause exhaustion, there are a few such as the Sibriex, Gingwatzim, and Atropal. These can serve as inspirations for creating your own custom monsters that sap your players’ stamina and make exhaustion a constant, terrifying threat. A homebrew rule I use in all my D&D 5e games is that when you drop to 0 hit points you IMMEDIATELY take a level of exhaustion. This cuts down on the yo-yo effect you often see in 5e combat because dropping to 0 hit points too many times can be BRUTAL.

2. Massive Damage 

This is a classic. By the book, if a character takes damage that reduces them to 0 hit points and damage remains, the character dies if the remainder equals or exceeds their hit point maximum. However, past second level or so, this rule rarely comes into play, especially for anyone with decent HP. So, this method is basically worthless…unless we tweak it.

3. Alternate Massive Damage Rules 

In the Dungeon Master’s Guide on page 273, there’s another option: if a character takes damage equal to over half of their hit points in one go, they must make a DC 15 Constitution save. Failure means they suffer a random effect determined by rolling on the System Shock table, and one of the possible results is dropping to 0 hit points. This adds a bit of realism, right? A single massive hit doesn’t just hurt—it can take a character out of the fight entirely.

To keep this relevant in your game, you might consider adjusting the DC to scale with character level for extra challenge. I would probably increase the DC by 2 for every tier of play. So, at tier 2, the DC is 17; tier 3 the DC is 19; and tier 4 the DC is 21.

However, the problem is that VERY RARELY does a character ever take damage equal to over half their hit points from one attack. So, I would tweak this rule just a bit. You could make it so that instead of one attack its damage during an entire round, though that’s perhaps harder to track. The other option is to set the damage threshold from a single attack to the character’s Constitution score, though that could be fairly brutal; so, maybe go with 10 plus their Constitution score.

4. Fewer Death Saves 

Here’s a house rule for the “old school” D&D enthusiasts: fewer death saves. Instead of the usual three death saves, maybe characters get only ONE shot at it, or two if you really want that natural 1 to still mean something big. This is a brutal tweak but one that makes going down way scarier.

You can also ramp up the suspense by rolling death saving throws yourself as the dungeon master. That way players have no idea if someone is close to dying or not. Besides increasing the drama, it also eliminates the possibility of metagaming.

5. Death Saves Reset Only on a Short Rest 

If you want death saves to matter more without losing the full three saves, try resetting them only after a short or long rest. This makes getting back up mid-fight far riskier since it doesn’t reset the death save tally until they can truly rest. It also encourages players to fight tactically and get creative instead of just banking on those three saves every time they go down.

6. The Wounded Condition 

The “yo-yo” of dropping to 0 HP, then bouncing back up, but still being at full fighting strength can feel a bit silly. Enter the Wounded Condition. For each time a character drops to 0 hit points and rises again, they suffer a -1 penalty to all rolls, up to -5, until they can take a rest. It’s a subtle but cumulative effect that adds tension without making characters outright unplayable. Yes, yes, I know, this is similar to just using the 2024 exhaustion mechanic when characters drop to 0 hit points, but it’s not nearly as brutal.

7. Negative Hit Points 

This one is a throwback rule that eliminates death saves entirely. Instead, characters track “negative hit points” after they drop to 0 hit points, and unless they are stabilized, they continue to lose hit points each round at the start of their turn. Maybe it’s just 1 hit point, maybe it’s 1d6 hit points. Then, once they reach a certain threshold, such as -10, -10 + their Constitution modifier, or even their Constitution score in negatives, they’re dead.

Furthermore, taking damage while unconscious makes a character who had been stabilized to no longer be stabilized, and taking damage in this way could kill outright the character. And, of course, this house rule makes it possible for a character who is still up but low on hit points to be killed outright from an attack that deals enough damage to take them past their negative hit point threshold. This mechanic not only makes going down in combat a BIG DEAL, but it also makes just being low on hit points a problem. Overall, it increases REALISM and moves the game away from superhero play.

8. Healer’s Kit Dependency 

This rule from the DMG on page 266 adds realism by requiring a character to use a charge from a healer’s kit to recover hit dice on a short rest. However, healer’s kits aren’t overly expensive or heavy, so players are likely to just stockpile them if you use this rule, even if you track inventory and carrying capacity…which most groups don’t. So, while an option, it’s rather worthless, and now I have no idea why I even included it in this article…

9. Slow Natural Healing 

Another DMG option is slow natural healing. This stops players from regaining all of their hit points after a long rest; instead, they must use hit dice to heal up. This option is perfect for gritty, more realistic games where the party must rely on resources and downtime to recover. The book doesn’t exactly say when they recover spend hit dice, nor if hit dice can still be spent on short rests. But this is the way I would do it: on a short rest, hit dice CANNOT be used to recover hit points; on a long rest, you can use hit dice to get hit points back; and, finally, you get your hit dice back after you take a long rest where you do NOT use hit dice to recover hit points.

10. Gritty Realism 

If you really want to slow things down, try the gritty realism rule on page 267 of the DMG. Here, a short rest is 8 hours, and a long rest takes a full week. This makes magical healing invaluable and makes every wound count. But be prepared: the players may want to leave the dungeon more often to get their rest, so this will probably affect gameplay. Specifically, you’ll need to consider what the bad guys do when they discover half their force wiped out. Do they get reinforcements from the next tribe over? Do they fortify the entrance and increase patrols?

11. Monsters that “Kill” 

Certain monsters can outright kill characters. Banshees and Bodaks are known for this ability, and creatures that can petrify are particularly dangerous: basilisks, cockatrices, and medusas. The problem here, though, is that you probably don’t want to FILL YOUR ENTIRE GAME with a handful of the same creatures, so the utility of this method is very limited.

12. Drowning and Suffocation 

When water does come into play in your game, remember that suffocation is a serious threat. Players can hold their breath for 1 + their Con modifier in minutes. Once that’s up, they have only a few rounds before they start making death saves. Furthermore, a creature that is surprised by a sudden lack of air can’t hold its breath and immediately begins suffocating as if it ran out of breath.

Now, generally speaking, most characters can hold their breath more than long enough to get them through any combat situation. So, a house rule you can apply is to force a character to make a Constitution saving throw any time they take damage while underwater. The DC should be 10 or half the damage taken, whichever is higher. If they fail, the damage causes them to immediately exhale, and they begin suffocating.

13. Diseases 

Diseases often get sidelined in D&D, but don’t underestimate their power. The DMG includes some deadly options, like Sewer Plague, which causes exhaustion over time. Furthermore, you can homebrew diseases that are harder to resist or have more severe effects for higher-level characters to keep the threat looming.

14. Cursed Magic Items 

Cursed items don’t usually kill characters outright, but they can set up deadly situations. A Berserker Axe, for example, could force the party to subdue one of their own, potentially leading to a deadly outcome. It’s a way to introduce mortal danger without directly targeting hit points.

15. Sanity and Madness 

Finally, we have the Sanity and Madness rules from the DMG. While they won’t directly kill a character, they can remove them from the game in a different way: by becoming completely insane. This mechanic adds a level of psychological threat that can have lasting consequences and leave your players on edge. I think this would probably work best with horror campaigns, though. I will say, though that the sanity and madness rules in the DMG aren’t particularly satisfying, in my opinion. So, my team and I did make our own Insanity System if you’re interested. You can pick it up in Lair Magazine #14, Sanity & Sabotage.

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