In addition to a handful of options found in the Dungeon Master’s Guide, I made a small handful of ideas and options for grittier and darker D&D games where healing powers aren’t prominent and health is usually a concern. Whether these are mixed and matched with your games is completely up to you.
NOTE: This will make your game much more lethal. More characters will likely die as a result of these house rules.
Sacred Healing: In worlds overrun with wickedness, it truly takes a toll on the body. In order to heal up to full HP after a long rest, you must be in a holy site; a temple, a sacred druid grove, a special divine landmark, etc. Evil characters must seek desecrated and unholy lands. If the character cannot find a location like this, they do not gain this benefit.
Comfort and Joy: You may only spend hit dice if you’re resting in a comfortable environment.
Longer Rest Time, but not TOO long: Short Rest is now 3 hours and Long Rest is 24 hours. Under this module, you could use a day of downtime during the long rest.
Less Intense Long Rests: You regain HP = your remaining hit dice + your level. You regain hit dice after the end of your long rest.
Slower Healing Magic: Healing magic and healing-related powers (like Lay On Hands) would have ritual casting time. Higher level and more elaborate spells (like Raise Dead) take a couple of hours instead.
Bring on the Pain!: Consult the “Death and Dismemberment Chart” for dying characters.
More Pain!: Here’s my take on Death & Dying. Roll from either of the following d10 tables when you’d normally roll death saving throw. Getting attacked requires you to roll again.
* Table 1:
- 1 – REALLY Dead (You are dead but CANNOT be resurrected),
- 2 – Dead (You are dead but can be resurrected)/
- (Alternatively) 1 – 2 – Just Dead (ignore resurrection related content),
- 3 Almost Dead (Fail 2 Death Saving Throws),
- 4 – 8 Dying (Fail 1 Death Saving Throw),
- 9 Not Dead (Succeed Saving Throw),
- 10 Miraculously Invigorated (Automatically Stabilized)
* Table 2 (alternate):
- 1 – 2 – Death,
- 3 – 4 – Almost Dead (2 Fails)
- 5 – 7 – Dying (1 Fail)
- 8 – 9 – Nothing Happens
- 10 – Success (1 Success)
Death and Dying: Nightmare Mode: You die at 0 Hit Points.
For rules like this and more, please check out the D&D 5th Edition Dungeon Master’s Guide.