The Alexandrian – Misc Creations has an interesting take on Save or Die effects. I’m currently running 4e where there are a lot fewer of these but I may end up running Pathfinder and I’ll have to review how that systems handles save or die.
The problem with save-or-die mechanics is that they bypass the ablative combat mechanics that work so well. So here’s my thought: Instead of just watering these effects down, let’s change the paradigm entirely and tie them into the ablative damage system.
The simplest solution is to simply have save-or-die effects deal ability score damage. For example, in my house rules all death effects deal 4d6 points of Constitution damage. If the spell has a secondary effect — such as turning the victim into a pile of dust — this effect only happens if the victim is killed by the Constitution damage. Similarly, you could have paralysis effects dealing Dexterity damage.
If I was completely overhauling the system, I would — at the very least — vary the amount of ability score damage depending on the power of the effect in question. For example, death effects might vary from 2d6 to 4d6 points of Con damage depending on whether you were talking about a 6th-level spell or a 9th-level spell.
But you can also get fancier: For example, if I were redesigning hold person I would make the spell deal 1d6 points of Dexterity damage per round until the victim made a successful save. If the victim is reduced to 0 Dex as a result of the spell, they are paralyzed (as the magical energies of the spell bind their limbs completely).
Similarly, a victim of a medusa’s gaze would feel their limbs turning to stone as they medusa repeatedly inflicted them with 2d4 points of Dexterity damage.
Under this paradigm, there would be no need for a “paralysis” condition — paralyzed creatures are simply those which have been reduced to 0 Dex. Similarly, a spell like remove paralysis would just be a quick way of healing Dexterity damage.
A sleep spell would be a mental assault, inflicting 1d4 points of Wisdom damage per round until the victim makes a save or drops into a magical coma. When the sleep spell wore off, this Wisdom damage — like the damage from a ray of enfeeblement — would be restored.
Since ability score damage no longer exists in 4th Edition, this solution won’t work for that game. But if I end up making the switch, I’ll be looking for some similar means to change the paradigm of save-or-die effects — rather than just watering them down.