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More Realistic Healing Rules (5e D&D)

The more I play 5e D&D the more I feel the designers got a very complex balancing act almost exactly right. Sure a few feats (Luck and Great Weapon Master!), spells (Counterspell) and special abilities (Divine Smite and Wild Shape) can feel overpowered, but considering the task at hand you have to say hats off, great job.

One significant thing that bugs me though are the official rules to do with healing and rests. All too often a character that just moments ago was clobbered to zero hit points by the spiked club of a stone giant, on the cusp of death, can restore themselves to full health by laying down by a grassy knoll for a 60 minute siesta. Quite aside from this assault on our credulity, the overpowered nature of rests also undermines magical healing like Cure Wounds and Lay on Hands, an important function of clerics and paladins.

What are you doing? I just need a short rest!

After a minor 20 year hiatus from the world of fantasy (during which time I even considered it a bit naff), one of the reasons I got back into Dungeons & Dragons was the sheer awesomeness of Game of Thrones. With its gritty realistic take on the genre and a strong focus on intrigue, war and politics I started to see fantasy through a new lens… it didn’t have to be a cheesy battle of good vs. evil that relied on epic monsters and magical effects to keep its audience entertained. Done well and fantasy could be complex, character-driven and credible – but to do so it has to employ the same techniques used by the best storytellers in every other genre. The fantasy element should be the delicious icing on the spongey goodness of a believable plot line, not the cake itself.

Since realising that I’ve tried to inject as much realism into my return to D&D as possible, as both a DM and player. If I’m the DM and I throw a band of goblins at the party then there needs to be a reason for that… why are these goblins in the area? How do these goblins survive? Where do they live? If they ransack every caravan that passes how does trade even continue to exist in the region? I want the worlds I create and play in to make as much sense as possible… just as George R. R. Martin’s Westeros does.

It’s my love of realism that means I take issue with the healing rules in 5th edition D&D, and the short and long rests mechanics. Chilling out for an hour after every combat shouldn’t be enough to mend broken bones, seal critical wounds and have arrow-sized holes in your torso magically clear up – nor should this frequently-taken power nap work better than most healing spells and magic potions. As for the long rest, whilst everybody loves a good night’s sleep, the crazy mechanics that you restore all HP are such you never carry an injury, no matter how severe, into the next day (let alone the rest of your life). It feels like a computer game power bar that charges up the moment you stop taking hits, which might be convenient for a shallow hack’n’slash campaign, but creates friction for those of us who want to try and believe in the worlds our characters inhabit.

The awkward moment your Rage ends…

Of course full realism for wounds and healing (I know there are some smart asses who are going to bring this up) can’t work. If that was the case you’d have to roll for potential infections for every scratch and mighty warriors would soon go the way of the way of Khal Drogo or The Hound, taken down by “flea bites”. And that’s not to mention the tedious accumulation of effects of being injured several times a day that would make gameplay a nightmare.

Official Rules: Optional Healing Variants

Taking a look at the official optional rules for rests etc. (p266 and 277 of the Dungeon Master’s Guide) there are two options that make healing even easier (cue me smashing my head against wall) and two that make it harder, so let’s take a quick look at them. Slow Natural Healing is the method that one or two of the DMs in my group use. Every day you get a full complement of Hit Dice to employ at the end of short or long rests, which is way better than getting all your HP back and full complement of Hit Dice (as per Player Handbook, p186), but still allows you to power back from the edge of death in a jiffy if needed. The Gritty Realism option however then takes thing way too far the other way… a short rest takes 8 hours and a long rest 7 days! That changes the game so radically that it’s not something I really want to even try out. It would also have a major effect on abilities and spellcasting (unless they operate under normal rest rules… it’s not really clear).

Nope, I’m going to have to sort this one out myself…

Hipsters & Dragons’ Healing Rules

To resolve this gameplay issue to my satisfaction I’ve homebrewed these optional healing rules that I believe provide a nice balance of realism and simplicity, giving the PCs something to worry about (“guys, maybe we should parlay this encounter!?”) without hamstringing them. In fact I already playtested them during a recent adventure and I was pleased with the results (the time limitations on short rests meant there were a few grumbles from the fighter in our party when he found out he can’t get all his superiority dice back after every combat anymore…. but I’m also all for PCs having to go into fights without all their powers on occasion).

Let me know your thoughts and if any feedback you might have from playtesting them… I may well fine tune them in future.

General Rules

A character can benefit from a maximum of three rests in a 24 hour period, either one long rest and two short rests, or three short rests (if for some reason there is no time for a long sleep at the end of the day). Rests must be spaced at least four hours apart, if a character is to derive any benefits from them.

Long Rest

At the end of a long rest a character recovers HPs equal to half their hit dice rounding up. Ie. a 9th level character recovers 5 hit dice worth of HP. They must roll each dice.

Short Rest

At the end of a short rest a character may recover one hit dice for every four levels they have. Ie. levels 1-4 = 1 hit dice, levels 5-8 = 2 hit dice, levels 9-12 = 3 hit dice etc. They must roll each dice.

Treating Wounds (adding Constitution Modifier)

A recuperating character may add a positive Con modifier to each hit dice, if they have one, only if their wounds are successfully treated. To be considered treated either they themselves (depending on location of wound, DM to decide) or someone else in their party must make a Wisdom (Medicine) check DC15. If this person employs one use of a healer’s kit (p151 PH), the DC is reduced to 10.

NB: As I consider Medicine ‘a technical proficiency’, non proficient players would get disadvantage on this check… suddenly it pays to actually have someone with Medicine proficiency in the party!

If the character has a minus Con. modifier the same Medicine check can negate it.

Severe Injuries

It also annoys me when characters with 1 HP run around the place as if they have never felt better. Here are a couple more optional rules you might like in order to add a dash more realism to your game.

Critically Injured: Ask your characters to make a note of what 10% of their maximum HP is (or 15% if you want to be tougher on them!) rounding any fraction, no matter how small, upwards (ie. 10% of 11 HP in this case becomes 2 HP). When characters equal or fall below this amount of HP, they automatically suffer the effects of one level of exhaustion and must make a Constitution Saving Throw DC10 to avoid suffering from two levels of exhaustion.

Last Legs: Any PC on 1 HP automatically suffers from two levels of exhaustion and must make a Con Saving Throw DC15 to avoid suffering from three levels of exhaustion.


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  1. Ramon F

    As for the running around just fine at 1 hp I advised I plan to add exhaustion 1 at 50% damage, exhaustion 2 at 75% and exhaustion 3 at 1 hp.

    I also made exhaustion levels more gradual and easier to recall. Reduce one on roll to hit and one block of 5 feet movement for first two levels. third level drops to half move and disadvantage on all rolls. Not different in theory or degree from previous just graduates each effect instead of sudden loss at given level.

    Level 4 drops to 5 ft move and no actions other than brief sentences and drinking water.

    Level 5 is conscious, but unable to do anything more than drinking safely.

    Water intake actually allows the body to replenish blood somewhat once the leaks are plugged, so the drinking matters in addition to potions.

    Using optional rule med kit dependent on all healing not of magical spell origin or class/race specific trait. Helaing without one is limited to 1 hp after 1-4 hours as per RAW in recovering from zero and then only 1 hp on first short rest, 1 hp on first long rest, then 10% of total hp per week. I make med prof required on any med kit use and mandatory to use advanced med kit, but if proficient no roll is required to use it. Double proficient permits advanced med kit using magical herbs, but while they cost same as a fast acting potion can give 10 times the results at a short rest as required to activate HD healing. normal med kit gives only stabilization and permits one hp per hit dice of healing on short rest or 2 per hd on long. (and only if taking in fluids) . Advanced med kit uses magical herbs, plus combat medic skills, and permits normal RAW hd healing, but becomes a fully magical healing task that simply uses a much slower acting magic source. Normal healing classes get medicine proficiency by default. Others can study it for a price at any decent sized city or outpost with a professional healer during downtime. Magic med kits use some of the same components as healing potions, but also medically significant natural herbs, but are not actually not magicked to give instant results. Instead the magick in the special herbs themselves (think goodberries or willow bark from one near a magic pool etc) radically speed natural healing process and medically treat the infections, blood loss, pain etc. This way suspension of disbelief is no greater than for healing spells and simply gives a much more vibrant and interesting medical field that makes medicine expertise supreme. Medicine feat still is good in that it really saves your hd as get max results on every roll. Should also add in the ability to use herbs to cure disease, poison etc on level of the spell, though perhaps a bit slower results like over a rest period.

    • duncan

      Hi Ramon, your rules make decent sense from a realism point of view although you will need to do A LOT of tracking and players may get frustrated as they’ll often be exhausted. Will you apply the same to monsters as well?

  2. Ricz

    Great homebrew. I could never really get on board with the fact that RAW PCs can recover from the most grievous of injuries with a quick 40 winks.

    I’d perhaps make a couple of changes. It seems a little to harsh to me that after a short rest (or even a long rest a low level) a player may only gain 1 or 2 hit points due to an unlucky dice roll. I’d probably change it so players can add their Con mod to each hit dice without the medicine check, The ‘treating wounds’ mechanic I’d keep but on a successful medicine check I’d let the player use their hit die maximum rather than roll.

    • duncan

      Hi Ricz

      I like your proposal, and I think I’ll probably use that over what I originally wrote.

      Right now in fact my DM is using another variant. He is saying quarter of your hp back from a short rest (third if someone passes their medicine check) and half back from a long rest (two thirds on a successful medicine check).

      We only just started using it but so far it’s nice to do away with all the tedious dice rolls and totting things up, and quickly work out what hp you’re on and get back into the adventure.



  3. Steven Victor Neiman

    This only matters from the realism side, not the gameplay side, but it’s worth noting that hp is NOT just a measure of ability to withstand injury. Hp represents a much more abstract concept of how much fight you have left in you.
    For an example, I do martial arts, and quite enjoy sparring even though I’m not great at it yet. The worst sparring injury I’ve ever suffered was a sprained thumb, and that was very unusual and only happened because I did something stupid (forming my fists badly, with the thumb out). However, if I came out of a busy sparring day, I’d just peeled my gear off and gone outside and someone attacked me I would be at a major disadvantage.
    In D&D terms, that would be because I had lost some hit points to the sparring. Not enough to be critically low, maybe as low as half health. Instructor wouldn’t let us continue if he thought we were much lower than that. What’s important is that even though I don’t come out of a sparring match critically injured, my ability to avoid being disabled by an attack is reduced. However, give me an hour to cool off and get some lunch and I’ll be nearly back to full effectiveness. I couldn’t keep doing that over and over for a whole day, but once or twice I can bounce back from. That’s how spending hit dice on a short rest works.
    The last hit or two you take before collapsing are where you first start to get real injuries. You might see blood as early as the first hit, but it’s not going to be more than scratches for a long time. I do like the idea of taking exhaustion (or some other penalty) if you drop below a certain threshold of your hp though, to represent the fact that you are actually starting to get seriously injured by that point.
    That said, the next 5e campaign I’m running I’m actually going to have pretty heavily restricted healing for reasons related to the gameplay loop I want to encourage. My rule will be that everything except hp and hd recover like normal, but hd only recover on a one-week extended rest, and you only get one unless you spend that rest somewhere comfortable. Long rests let you spend any number of HD, and short rests let you spend up to one quarter your max hd. This is because I want to tie the PCs to their home base, and encourage them to go scouting in the wilds and then come back home for a week and deal with base building and politics.

    • duncan

      “The last hit or two you take before collapsing are where you first start to get real injuries.” Interesting way of imagining HP and injuries, I’d not thought or heard of that before.

      Thanks Steven for the in-depth comment on this and other posts. I’m crazy busy with work and travels atm, but I’ll hopefully pick up on some of the points you’ve made across the blog as and when I have a bit more time!

    • Victor Pitts

      Good points on the meaning of HP

  4. Troy

    I agree with Victor’s point. Unfortunately, Critical Role narrates damage in video game style, like losing a chunk of shoulder every time you get raked by a monster’s claws.

    I practiced and taught martial arts for a number of years and the number one factor is endurance and, cliche as it sounds, fighting spirit. HEMA in particular has you going at it with full power, wearing full plate; guys (and gals) go in fresh and after a minute’s bout, come out looking like boiled lobsters although maybe that’s partly down to us doing it in the South African summer. I also worked on an ambulance for a bit so have some practical experience with injury, including my own… so I’ll try and describe what I think would work.

    With plate, mail and even padded armour (gambesons), the severity of wounds is vastly reduced. Helmets are the number one defensive item after shields, even if, say, it doesn’t add to AC. Actual battles lasted for hours. Getting a lethal stab within the classic eighteen seconds is unlikely unless it’s a surprise attack behind the tavern. The video game notion of DPS goes out the window if you have the prospect of getting stabbed in the face… that is probably the most unrealistic part of D&D combat. Human beings are champions at endurance and can literally run other animals to death, even if we are screwed if the bear gets the drop on us from behind the bushes. Fights are going to be long, sweaty affairs as each side sizes each other up, shouts, taunts, shakes spears or roars, and then feints, crashes against shields and so on. Al, while lugging the gold chests, spare throwing axes and the decaying goblin heads at their belts that they forgot about. So I’m quite lax on how long a round actually lasts, and Constitution becomes a proxy for stamina and tolerance for heat exhaustion.

    Actual wounds tend to be pretty binary. Either it’s superficial (eg knife fight defensive wounds) or you’re out of action (a broken leg; a knife in the kidney). Adrenaline masks a lot of pain so you can continue to fight for a short while without losing effectiveness. Arterial blood spurting out; not so much.

    Superficial wounds can be cleaned and bandaged, and they’ll heal in a week or two in the real world, and we can ignore things like nerve damage because magic and we’re playing D&D instead a factually compromised medical drama.

    Treating a potentially fatal injury can also be as simple as rolling someone into the rescue position so they don’t choke on their own vomit, or giving someone a rehydration drink who’s on the verge of heatstroke. Putting pressure on a wound so they don’t bleed to death. In these sorts of situations, the 0 hit point patient can be back on their feet within an hour, although not operating at 100%. But if you have a snapped-off goblin blade that’s punctured the patient’s liver, you need the fantasy equivalent of Casualty. Magic could easily surpass our best trauma medicine. Mage Hand to pinch a severed artery. Create saline solution or real blood directly in the circulatory system of a patient. Completely eradicate infection by a Paladin laying a hand. Magically suture injuries with collagen weaves. If you can turn a dragon into a snail, magic can certainly get someone back on their feet.

    So where am I going with all of this?

    Make short rests interesting. The fight is over, and now with your Medicine roll you can discover that Kate McMuscles suffered an injury which pierced her spleen, and it might be best to hightail out of there for some magical surgery. Give XP for successful Medicine checks, or maybe Inspiration.

    One last thing: at my table, pouring healing potion down an unconscious creature’s gullet insta-kills them. I always correct the players if they do that, simply because they may remember it and save someone’s life in the real world by not compromising a patient’s airway.

    • “One last thing: at my table, pouring healing potion down an unconscious creature’s gullet insta-kills them. I always correct the players if they do that, simply because they may remember it and save someone’s life in the real world by not compromising a patient’s airway.”

      It’s magic.

  5. Jonathan M Lewis

    Many of us have always thought that hit points represent not just physical health, but also stress and exhaustion. The more experienced a character is, the more he can handle the stress of battle and the longer he can endure intense activity. Hit points could also represent your defensive fighting skills;a more experienced guy gets better at dodging and parrying, but everyone has more difficulty with this the longer he spends fighting. It could also just indicate your spirit and morale. A person starts to lose confidence and enthusiasm after hours of fighting, running, jumping, all that. In this case, healing is really just feeling more motivated again. Factors like religious fanaticism could influence this.

  6. Thanks for this post! I am always interested to see how people adjust the healing system to make it less like a video game where you leave combat and recover your full HP Bar.™

    I do like some of the changes you have made, though I would suggest you remember that hit points aren’t meat points. Getting hit for 30 damage by the giant’s spiked club doesn’t actually mean you were impaled by a sword-sized nail driven through a tree trunk. If you had actually been so brutally struck, you’d have broken (or crushed) bones and wouldn’t be standing back up anytime soon.

    That kind of thing only happens when you fall to 0 hp. If you don’t fall to 0 hp, it’s safe to assume that the you (narrowly) dodged out of the way, or somehow managed to avoid the blow.

    This is how hit points have always been meant to work. A lot of people who write posts like these generally don’t understand this, hence why they feel the system needs to change. They think that hit points are like video game hp, and treat encounters as a race to hit the enemy until they break.

    Obviously, if you get smashed to a pulp, you need something more than a nap. But if you’re just a little bruised and winded, a night’s sleep would probably be of some great benefit.

    I wrote my own article about how to treat hit points that expands on this. You can read it at the link below.

    • duncan

      Hi Taylor, thanks for the comment, I do agree with everything you say. I wrote this article pretty early on into my 5e experience. I’ve since reframed hit points to interpret them more in line with the designers intent… although the fact that the designers don’t really elaborate much on their intent in the PH was a source of frustration when coming back to D&D after a LONG break.

      Overall hit points work brilliantly as a game mechanic, but you have to be ready to twist reality in a very inconsistent way to get any sense from them. I believe that long time D&D players (as I am now, but wasn’t necessarily when I wrote this post), become almost immune to their nonsensicalness over time, given that they do their mechanical job so well.

      Nice to meet a fellow blogger by the way!

  7. Pact

    I like these more grounded healing changes.
    I’m also debating changing the magic heals, I feel like they should function the same as vanilla in combat, making them quick powerful solutions to injury. But after some amount of time the potency of healing magic lessens.

    My idea is that magic can “reverse time” on the injury, as long as not too much time has elapsed. Or something like that.

    • duncan

      Interesting idea, although requires a bit of extra bookkeeping regarding what wounds were dealt when etc.

      Actually what I don’t like in the official rules is that simply resting is often more powerful than magical healing, when it really feels that it should be the other way around.

  8. riley

    Having healing be more difficult may solve a lot of problems with DND 5e.

    With the way healing is done in 5e, unless it is a deadly encounter there are ZERO stakes: they can short rest for quick health, and in max 8 hours (less if you are an elf) they will get everything back.

    Lack of stakes, of risk, or player control, is the KEY INGREDIENT for making the storytelling exciting , engaging, and fun.

    If healing is slow… suddenly a goblin ambush has serious ramifications….

  9. Brad

    I’ve started adding mechanics such as broken bones, or a torn muscle. It takes a month with a long rest a day to heal. While you gave a broken leg, your movement is split in half and you can’t swim/climb. If you broke an arm, you cant use that arm for anything(No two handed weapons, two weapon fight, bows).

  10. Scaramouche

    If D&D didn’t only highlight combat and it made other competitions (social, entrepreneurial, minigames) rewarding, it wouldn’t need a robust healing recovery system. The problem is when most of the party is severely wounded some DMs think they cannot challenge their players until their PCs are healed. That’s the real problem, IMO.

  11. Randomwraith

    I’ve just started a 5e D&D campaign, Dad’s & kids, and we just encountered the overly generous healing aspect. It’s an odd thing and as suggested completely makes cleric/healer characters pointless and totally contrary to our experience with 1e/2e for example.
    We’re trying a 1HP per hour up to six hours and then 1 hit die per day after that for longer rests. The short rest essentially patches you up and provides some level of recovery. I think if you’re looking to home brew rules a level of detail which covers broken bones, torn muscles, critical hits, fatigue and the like you’re probably really better off switching to a system like RuneQuest or WHFRP.

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