(i) in the terminal phase of an incurable or irreversable illness;

(ii) permanently unconscious;

(iii) in a persistent vegetative state; or

(iv) so seriously ill that I am unlikely to recover to the extent that I cannot live without the use of life-sustaining measure,

then:

(v) I do not wish to receive or have administered to me any medical treatment, other than palliative care, even if that medical treatment is necessary to prolong my life and the refusal of that treatment will lead to my death;

I do not wish the provision to me of life sustaining measures, being medical treatment that supplants or maintains the operation of my vital bodily functions that are likely to be incapable of independent operation including life support, assisted ventilation, artificial nutrition, artificial hydration and cardiopulmonary resuscitation.