What balance issues would arise from a house rule imposing a saving throw versus exhaustion after a PC falls unconscious?

Question

In my last campaign, some combat encounters got pretty ridiculous, mainly due to some player characters falling unconscious and getting back up every turn. I remember one combat encounter in particular, during which the cleric of the group had his turn right before the rest of the party in initiative order. They got knocked down by the enemies, and then the cleric brought them back to consciousness with a mass healing word. They stood up, had their turn and were reduced to 0 hp again. This happened like 4 or 5 times in a row.

The players were glad that they survived this encounter, but agreed with me, that this little procedure of losing consciousness, then bouncing back, over and over again, is kinda stupid. So, I envisioned a homebrew rule to deal with this situation:

After regaining consciousness, the character would roll a Constitution save with DC 10. A successful save would result in no bad consequences, but the next time this happens, the DC would be increased by 5. On a failed save, the character would gain a level of exhaustion and the DC for the next time this happens would be back to 10. After a long rest, the DC is set back to 10 as well.

This way, there is an inherent downside to repeatedly falling unconscious, but it’s not immediately crippling for the character. (Plus, this house rule would be applied to enemies as well, unless they are undead or constructs).

Note: In my campaign, NPCs make death saves as well. The number of death saves they are allowed to fail depends on their importance to the campaign. Named NPCs (regardless of whether they are allies or enemies) usually die after two failed death saves, whereas unnamed NPC die immediately or after one failed death save, depending on the situation. This allows NPCs to roll a Natural 20 and rise with 1 hp, which has led to some really awesome moments in my campaigns.

Now my questions are:

• Will this houserule unbalance my game?
• Do you see any likely troubles that will result from this?
• Does this unfairly favour/disadvantage any characters (classes, races, archetypes)?

Answer 1

This house rule will almost certainly change the balance of your game -- by making it more lethal -- but whether it will "unbalance" your game is for you and your players to decide together.

Imposing save-versus-exhaustion rolls when PCs regain consciousness after dropping in combat creates a nontrivial risk of a so-called "death spiral." Once your players start losing, they'll lose faster and harder.

The first two levels of exhaustion will make combat modestly more difficult, but at the third level of exhaustion, characters suffer:

Disadvantage on attack rolls and saving throws

PHB p. 291 (emphasis mine). Once that happens, your PCs will suddenly find themselves failing spell saves they would otherwise make; taking damage they otherwise wouldn't take, and so falling unconscious more often; failing death saves they would otherwise make; and failing further saves versus exhaustion if they manage to regain consciousness before dying. Remember that death saves are already challenging, because with rare exceptions they are flat rolls with no modifiers for, e.g., high attributes or proficiency. Making death saves with disadvantage will make double-fails on rolled 1s more likely, and will make it dramatically less likely for anyone to roll that clutch 20 and spring back up with 1 hit point. (See PHB p. 197.)

And just to drive the point home, I'll note that a PC's hit point maximum is halved at four levels of exhaustion, and at six, the PC straight-up dies. No save, no second chance. Dead.

Moreover, at least with respect to published adventures, you might find that PCs will already be suffering from exhaustion from various sources at higher levels of play. I recall my own experience going from Tier 1 to Tier 2 in Adventurers' League play and discovering that I spent roughly every other session with at least one level of exhaustion. Playing a monk, a class that tends to rely heavily on ability checks (for things like Acrobatics), and constantly having disadvantage on all ability checks was a drag. (And that's to say nothing of playing a mobility-focused character who often suffered from half-speed at exhaustion level two. Ugh.) Had I to contend with saves versus exhaustion every time I dropped in combat, I expect that character wouldn't have survived.

Further balance changes to consider: your house rule makes Constitution more important than it already is. Players wanting to avoid a death spiral situation might make different character-building choices as a result, so as to prioritize Constitution more highly. Be prepared for a party full of barbarians. Likewise, anything that grants a bonus to saving throws -- such as the monk's Diamond Soul ability (PHB p. 79), the bless spell (PHB p. 219), or the stone of good luck (DMG p. 205) -- becomes more valuable.

Finally, the other part of that third level of exhaustion -- disadvantage on attack rolls -- arguably affects non-caster classes disproportionately. Disadvantage on saves will of course make it more difficult for casters to maintain concentration-based spells. (See PHB p. 203.) However, a wizard can at least sling non-concentration, save-based spells (e.g., fireball) to full effect despite exhaustion. Martial classes whose efficacy is heavily dependent on connecting with attacks will have it rough when all of their attack rolls are made with disadvantage.

All that said, the relative lethality of a game is a playstyle choice like any other. Some groups enjoy a gritty game where death lurks 'round every corner. If your group digs that kind of play, and you all will be heading into a more lethal game with your eyes open to the possibility that it'll be a short one, then there's no reason not to do so.

Answer 2

Yes it unbalances the game

In the strictest sense of balance, this houserule does unbalance the game because it's a notable nerf to what is arguably the strongest spell in the game, Healing Word. In general, the nerf is entirely on the player's side since players get to make death saves while enemies generally just die when they hit 0 hit points. Even when you consider that your enemies might be able to make death saves, it doesn't necessarily offset the fact that those enemies aren't subject to multiple combats throughout their effective lives in the same manner as players.

Whether this is bad, unfair, or otherwise depends on the table and how they feel about it.

The impact of this rule will be felt pretty regularly if your table is comprised of glass cannons, since the enemies may be a lot more likely to play whack-a-mole with PCs. Conversely, if the party is comprised of ranged attackers, tanks, and other folks whom keep their distance when it makes sense to, then the impact to the overall game will be lessened by virtue of players not going down and popping up quite so regularly.

Because of this rule, you can probably expect uses of Healing Word to go down as the risk of someone going right down again is going to make that a less desirable spell. This will drive up usage of other healing spells like Cure Wounds, upcast versions of Healing Word, and anything else that increases the likelihood of someone being healed staying standing for more than a round.

Lastly, compared to other Clerics, Life Clerics will really get to shine, by virtue of their 1st level Healing Word spells regularly being able to keep pace with other cleric's 1st level Cure Wounds spells.

Answer 3

Your house-rule does not address the core problem.

Why is healing unconscious teammates so powerful? It comes down to action economy. Forgoing a bonus action to grant an ally one or more turns is simply too good of a trade. Your house-rule does not change this fact and therefore it does not fix the problem, it just weakens the party in a roundabout manner.

I suspect that the use of spells like healing word and mass healing word will not decrease much, if at all. Instead, the party will just have to deal with the exhaustion aftermath.

In fact, your house-rule affects the social and exploration pillars more than the combat, because the first level of exhaustion just weakens ability checks and leaves combat capabilities intact. Hard encounters will not become harder, but the rest of the day will be plagued with failed ability checks due to the exhaustion, which in turn will pressure the party into premature long rests and slow down the pace of the game.

The house-rule also skews the balance of some character options.

Characters who can cast greater restoration or death ward will have to spend slots to remove or prevent exhaustion.

Characters proficient in Con Saves (such as fighters), or that can improve saves (such as Paladins) are buffed. Meanwhile, characters that rely on ability checks (such as rogues, party faces, and skill monkeys) are nerfed.

Constitution becomes even more important than it already is.

Address the action economy directly.

Rather than weakening the party with exhaustion, I would alter the action economy so that healing an unconcious creature is inefficient. There are many ways to achieve this, I'll leave you with two examples: "all bonus action healing spells/features use an action instead"; or "when an unconscious creature receives healing, it is incapacitated until the end of its next turn".

Either of these ideas will make combats more deadly, so you will need to adjust the difficulty accordingly. However, unlike your current house-rule, the exploration and social pillars won't be affected, and the only character options skewed balance-wise are healing spells/features.

Answer 4

You can use the official rules just fine

... this little procedure of losing consciousness, then bouncing back, over and over again, is kinda stupid. So, I envisioned a homebrew rule to deal with this situation

With your rule you introduce a price for dropping in 0 hp. There is an optional rule for this already in the Dungeon Master's Guide. It is called "Lingering Injures", see DMG page 272:

Damage normally leaves no lingering effects. This option introduces the potential for long-term injuries.

It's up to you to decide when to check for a lingering injury. A creature might sustain a lingering injury under the following circumstances...

One of the circumstances is "When it drops to 0 hit points but isn't killed outright", which is exactly the situation you're talking about. Using this rule will make the adventurers lives quite harder (so it is "unbalanced" in that sense), it will also increase the value of magical healing.

You can freely bend the official rules in players' favor

If some options would be too harsh for your campaign, you can use a "light" version of the Lingering Wound table. Remove unneeded options (like Festering Wound, Lose a Foot or Leg, etc) and add more preferable ones (like "concussion", which causes exhaustion).

Answer 5

Get Gritty

As a bit of a frame challenge, it sounds like your table may be looking for some grittier realism with regard to healing and recovery - and 5e covers this with variant rules within the DMG without having to resort to houserules.

This doesn't mean you can't do the houserule, but you may be interested in some existing mechanics that may give your table what they're looking for.

The DMG Chapter 9 covers two major mechanics that are worth reviewing:

Slow Natural Healing (DMG, 267)

Characters don’t regain hit points at the end of a long rest. Instead, a character can spend Hit Dice to heal at the end of a long rest, just as with a short rest.

This optional rule prolongs the amount of time that characters need to recover from their wounds without the benefits of magical healing and works well for grittier, more realistic campaigns.

Gritty Realism Rest Variant (DMG, 267)

This variant uses a short rest of 8 hours and a long rest of 7 days. This puts the brakes on the campaign, requiring the players to carefully judge the benefits and drawbacks of combat. Characters can’t afford to engage in too many battles in a row, and all adventuring requires careful planning.

This approach encourages the characters to spend time out of the dungeon. It’s a good option for campaigns that emphasize intrigue, politics, and interactions among other NPCs, and in which combat is rare or something to be avoided rather than rushed into.

These rules/approaches don't necessarily resolve the bounce-back to consciousness in the thick of it problem, but they do look at what effect getting hurt badly may have on the rest of their day/week.

Answer 6

Yes, the balance will change

But that may not be a bad thing.

In fact, it's one of the things that Paizo is looking to change with Pathfinder 2 (citing D&D 5E's bounce-back as something they don't want). I'd link you directly to the playtest rules, but the site's been having problems lately, so it may or may not be up. I can, however, link you to the errata PDF which contains the latest version of the Death and Dying rules (enough changed that pretty much everything you need is there).

It still allowed for "Oh, you were healed? Great! You're conscious again" but with action penalties (see below). And of course, you start prone (standing is an action), not wielding your weapon (you dropped it, picking it up or drawing a new one is an action), so you're not going to be in the best shape just after you get healed. Best retreat! (At least most enemies won't have attacks of opportunity).

These rules might change in the coming weeks, Paizo's Jason Bulmahn has said that they've got about 4 different Death and Dying rules they want to try out and the ones that went to the printer were chosen in a "well we have to print something" situation.

In-depth details

This might give you some ideas of things to try at your table and see what works for you:

The gist of the action penalties requires a bit of an explanation if you're unfamiliar with Pathfinder 2 (which you undoubtedly will be). PF2 operates on a 3-action turn. Anything and everything you do is "1 or more actions." Move your speed? An action. Make a single attack? An action. Cast a spell? That requires at least 1 action (most spells are 2). Use a class feature? Requires 1 or more actions (Monk's Flurry: 1, Fighter's Power Attack: 2). Some things are Reaction (such as intercepting an attack with a shield or performing an Attack of Opportunity (a Fighter class feature)) of which you get 1 reaction per turn.

Then some conditions (like Dying) have a value on them to indicate severity (like 5E's exhaustion). Hampered 5: your move speed is lowered by 5 feet. Hampered 10? Lowered by 10 feet. Slowed and Dying are conditions of this type. Slowed reduces how many actions you have available on your turn by its value. The Dying condition is more complicated:

It has values from 1 to 4. When you first get brought to 0 hp, you gain Dying 1 (2 if it was due to a critical hit). If you take damage while already dying, your Dying increases by 1. On your turn you make a Fortitude (Con) save against the DC of whatever it was that took you to 0 (averaged and normalized down it works out to "roll a 11+ on a d20"). Success, you reduce your Dying by 1. Failure, it increases by 1 (if the value is 0, you lose the condition). If Dying reaches 4, yer dead.

When you lose the Dying condition (e.g. by being healed) you gain the Slowed X condition for 1 round, where X is the value the Dying condition had when you lost it.¹

So as an example, if you take enough damage to knock you out (and it wasn't a crit), when the cleric heals you, you:

• Only have 2 actions (instead of 3)
• Start prone (takes 1 action to stand)
• Don't have a weapon ready (takes 1 action to pick up the one you dropped)

The original rules had it so that being healed did nothing about you being unconscious or removing your Dying condition, which led to people dying with 100 HP left!

Anyway, happy experimenting!

1. _{Its unclear what happens if you have Dying 1 and make the save. One interpretation is you're conscious and have 1 HP and Slowed 1. Removing one sentence (interpreting it as a subclause of another sentence, specifically about being healed) means you are Unconscious, but not Slowed, and will "recover eventually (GM discretion)."}

Answer 7

Mass Healing Word is meant to work like that

How is restoring consciousness on level 5 more ridiculous than flying, scorching 116 square meters, bringing back the dead, or creating undead?

Mass Healing Word is a third level spell, that restores 1d4 + ability modifier HP. What good is it, if it can't reliably and consistently restore consciousness?

1d4 + 4 is 6.5 HP on average, a ridiculous amount on level 5. Not what you would expect from some powerful healing magic.

It is meant to do exactly what you complain about.