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Background The effectiveness of advance care planning (ACP) is contingent on the quality of clinician communication. However, the only validated tool to measure observer-rated ACP communication quality, Advance Care Planning Communication Assessment Tool (ACP-CAT), has not been validated in real clinical encounters and non-Western contexts.Aim The current study aims to assess the validity of ACP-CAT in assessing the quality of ACP communication between clinicians and patients with advanced cancer and advanced chronic kidney disease (CKD) in Hong Kong and compare against patient- and family-rated quality of clinician communication.Design This was a cross-sectional study. Adult patients were eligible if they were aged ≥18 years, mentally competent, and diagnosed with advanced cancer or advanced CKD. Patients, family members, and clinicians were recruited from outpatient clinics in five public hospitals and one home hospice setting. ACP conversations were audiotaped. Two independent raters evaluated the quality of ACP conversations using the ACP-CAT, a 20-item tool covering five ACP communication content domains and general communication skills. Patients and family members assessed the quality of ACP communication using the 18-item Chinese version of Quality of Communication Questionnaire (QOC). We assessed the psychometric properties of ACP-CAT including interrater reliability, convergent validity and discriminant validity.Setting/Participants A total of 137 ACP conversations from 137 patients (84 cancer, 53 renal), 107 family members, and 20 clinicians.Results The ACP-CAT exhibited high interrater reliability (mean Gwet’s AC1 = 0.81; 88.6% agreement. Convergent validity was demonstrated by the significant positive correlation between ACP-CAT total score and patient-rated QOC EOL planning subscale (r = 0.29, p < 0.01), family-rated QOC summary score (r = 0.27, p < 0.05), and QOC EOL planning subscale (r = 0.34, p < 0.01). Discriminant validity was demonstrated by the lack of correlations between ACP-CAT total and content domain scores with patients’ self-rated health status, information preference, and decisional making preference (all p’s > .05). While clinicians frequently explored patients‘ fears and general health goals, they rarely delved into important nonmedical priorities and valued life activities. ACP conversations with both patient groups rarely discussed selecting a health care proxy or exploring flexibility in decision making.Conclusions The ACP-CAT demonstrates strong concurrent validity with patient- and family-rated measures and ecological validity in real clinical settings in Hong Kong. Our findings support its use as a reliable tool for assessing ACP communication quality across cultural contexts.