The instructions are clear, but you're asking me to pay a heavy cognitive price to parse them.
You have a lot of active keys. I think showing a keyboard, with the keys highlighted and explanations attached, would be easier.
The mechanical explanations are clear but quite verbose. Unless you're purposefully text-forward, I would condense all of this into an explanation of "here are values that kill you when they reach 5", and [item icon]:[effect icon][op][value] for the rest, like [cigarettes icon]:[madness icon]-1. So 2 cards altogether, + the keyboard.