5e has a reputation of being extremely survivable. In previous editions, one tough combat could leave your party in shambles. Without a good well-stocked healer, you would face a TPK if the party ran blindly into combat again. Not so in fifth edition. The increased power of Rests in 5th edition gives DMs a real challenge should they be seeking to keep their players on death’s door.
Thankfully, the Dungeon Master’s Guide gives us some Variant Rules to manage healing and damage. I’ll be giving a short description of the variant options you should implement for your high-difficulty game – no homebrew necessary.
Healer’s Kit Dependency (DMG 266)
This rule requires players to expend a charge of their healer’s kit whenever they want to expend hit dice on a Short Rest.
The Mechanical Advantages: By vanilla rules, Healer’s Kit provides a guaranteed stabilization of a dying ally. As the Kit has no other use, players can purchase a Kit and be guaranteed that it will be available when an ally goes down. With the Healer’s Kit Dependency rule, Healer’s Kits will be in constant use. Players will not necessarily have charges available when their party members drop in combat.
The Roleplaying Advantages: Casts, bandages, and chemicals add some validity to the concept of Short Rests. Instead of sleeping off a chest wound, the fighter is taking painkillers and applying stitches.
Slow Natural Healing (DMG 267)
5th Edition Long Rests restore all lost hit points. The Slow Natural Healing rule changes Long Rests, so that players must expend hit dice to heal.
The Mechanical Advantages: Players will not charge into every combat fresh. Not only does this increase danger for the party, the party will also feel their level progression viscerally. As they level, they will notice a significant difference in the distance they can travel and the length of dungeons they can assault before requiring weeks of recuperation.
The Roleplaying Advantages: Elroy is crunched in the jaw of a dragon and comes within moments of bleeding out. Without the ability to rest and instantly recover, Elroy can roleplay the healing process and the trauma of a character who was truly moments from death.
Bonus! The Gritty Realism resting mechanic (DMG 267) increases the length of rest times significantly. This prevents parties from taking Long Rests in dungeons, outside of a secure camp or settlement. When combined with the rule above, it may prove too much of a slow down on a campaign. Should your players like Downtime Activities and urban roleplay, it could be a realistic addition.
Lingering Wounds (DMG 272)
Terrible scars and wounds can stay with a person, long after they heal. This mechanic gives the DM a random “Wound Chart” to roll on when players drop to 0 hit points, receive a critical hit, or fail a death throw significantly. These wounds do not vanish after the character receives traditional divine healing.
The Mechanical Advantages: Not only do such wounds create diverse situations that players must adapt to, but they also create an added danger for veteran characters. Without the funds to pay for significant healing, wounded veterans may quickly become unplayable after receiving multiple wounds.
The Roleplaying Advantages: Players can roleplay wounded warriors who have seen real combat. Such characters may be less interested in facing enemies head on and may be cagey if forced to tag along with green fighters.
Recommendation: I recommend restricting this to players who receive critical hits and also removing the bonus damage of critical hits. The healing process implemented above is deadly enough.
Disarm (DMG 271)
This rule allows players to disarm enemy combatants, through the use of a contested attack roll.
The Mechanical Advantages: This gives players a mechanic for deescalating dangerous situations, should they find themselves in combat without much health remaining. Disarming and surrounding an enemy gives them an advantageous position for forcing a retreat or parlaying with the enemy.
The Roleplaying Advantages: Players who have to rest for days, simply to reach full health, may be cautious about engaging in unnecessary combats. This rule lets them roleplay other solutions.
In Fifth Edition’s vanilla state, DnD does not provide tough-as-nails gameplay. Luckily, for those of us that enjoy brutal difficulty, the people at Wizards of the Coast have provided an alternate and extremely challenging ruleset. One benefit of avoiding Homebrew rules for ultra-difficult sessions is the incredible amount of playtesting and balancing that has gone into the Variant Rules of the DMG. After all, if you kill a few of your players – game balance will suddenly become very important to them.