Quote Originally Posted by Anonymouswizard View Post
Death does not have to be the only stakes, and overuse of death cheapens the stakes. At some point it becomes 'I died, oh well, somebody hand me a blank sheet'. Assuming the PCs have some form of goal setbacks can be more meaningful than outright death.

There's also an issue that D&D has very few mechanical setbacks other than 'you can't play for a while'. This isn't like Unknown Armies 3e where both the PCs and NPC groups have objective meters they can build, there's very few statuses that stick around, you can't really give a player a minor punishment and instead need to jump to major impediments. As controversial as they are at least death spirals inflict some kind of setback before 0hp.

Another idea, used in games like Fate or Storypath, is the idea of being Taken Out. Essentially when you take damage you can decide that instead of absorbing it by taking some form of penalty, you can declare you're out of the game for a bit and take no lasting consequences. Of course that only really works if there are consequences other than death.
I stand by the notion that Fate has much grittier and meaningful combat than D&D for just this sort of reason. It's the only game I've played where you can stumble out of a swordfight with a pierced lung and a broken arm and have those both be meaningful mechanically.